PRACTICAL  TREATISE 


DISEASES  OF  THE  KIDNEYS 


URINARY  DERANGEMENTS 


CHARLES  HENET  EALPE,  M.A.,  M.D.  (Cantab.) 

FELLOW   OF   THE    ROYAL    COLLEGE   OF    PHYSICIANS,    LONDON  ; 

ASSISTANT    PHYSICIAN    TO    THE    LONDON    HOSPITAL; 

FORMERLY    SENIOR    VISITING    PHYSICIAN    TO    THE    SEAMEN'S    HOSPITAL, 

(dreadnought)    GREENWICH,    ETC.,   ETC. 


WITH  ILLUSTRATIONS 


PHILADELPHIA: 

P.    BLAKISTON,    SON,    &    CO., 

No.  1012   Walnut  Street. 

1885. 


TO 

JOHN   WILLIAMS,   M.D.  Lond. 

FELLOW    OF    THE    ROYAL    COLLEGE    OF    PHYSICIANS,    LONDON, 

OBSTETRIC    PHYSICIAN    TO    UNIVERSITY     COLLEGE    HOSPITAL, 

ETC. 

THIS    WORK    IS    INSCRIBED 

BY 

THE  AUTHOR 

AS    A    MARK    OF    ESTEEM 

AND    IN    TOKEN    OF    A    FRIENDSHIP    OF 

TWENTY- TWO    YEARS. 


PREFACE. 

The  object  of  the  present  volume  is  to  present  the  student 
and  practitioner  with  a  clear,  concise,  and  systematic 
account  of  urinary  pathology  and  therapeutics,  based  upon 
the  latest  ascertained  facts,  and  supported  by  the  best 
authorities.  For  this  purpose,  I  have  endeavoured  to 
make  myself  acquainted  with  the  recent  Hterature  on 
the  subject ;  more  especially  the  contributions  made  to 
our  Societies,  and  the  discussions  resulting  therefrom. 
Throughout  I  have  endeavoured  to  put  prominently 
forward  the  characters  upon  which  the  diagnosis  of  the 
various  renal  and  urinary  diseases  is  founded,  and  their 
treatment  indicated. 

I  have  to  thank  my  friends.  Dr.  Green,  Professor 
Greenfield,  Dr.  Frederick  Eoberts,  Dr.  Lindsay  Steven, 
and  Mr.  Godlee  for  the  use  of  illustrations  from  their 
works,  and  must  also  record  the  obligation  I  am  under  to 
my  friend  and  colleague.  Dr.  James  Anderson,  for  the 
chapter  on  Abnormalities  of  the  Kidney,  which  his  ex- 


Vlll  PREFACE. 

teusive   anatomical   knowledge   peculiarly   fitted   him    to 
supply. 

My  former  work,  on  the  "  Morbid  (Conditions  of  the 
Urine  dependent  on  Derangements  of  Digestion,"  being 
out  of  print,  I  have  incorporated  such  portion  of  it  as 
seemed  desirable  in  the  present  volume,  so  that  it  will  not 
be  issued  again  in  a  separate  form. 


Queen  Anne  Street,  Loudon. 
Jtily,  1885. 


CONTENTS. 


CHAPTEE  I. 

General  Symptomatology  of  Kidney  Disease. 

Pain,  2.  Enlargennents  of  kidney,  4.  Anatomical  relations  of 
kidney,  5.  Renal  dropsy,  10.  Cardio-vascular  changes,  15. 
Uraemia,  23.  Acetonsemia  or  diabetic  coma,  28.  Neuralgia, 
32.  Ophthalmoscopic  changes,  34.  Renal  asthma,  38.  Pul- 
monary complications,  40.  Derangements  of  digestion,  42. 
Condition  of  the  skin,  42. 


CHAPTER    II. 

Clinical  Examination  op  Ukine. 

Method  of  procedure,  48.  Relation  of  urinary  water  to  the  solids, 
50.  Specific  gravity,  51.  Trapp's  and  Haesar's  co-efficients,  ol. 
Reaction  of  urine,  56.  Highly  acid  urines,  59.  Fixed  alka- 
line urine,  62.  Volatile  alkaline  urine,  63.  Urinary  pig- 
ments, 65.  Urea,  72.  Uric  acid,  80.  Urates,  81.  Hippuric 
acid,  85.  Phenylic  acid,  SO.  Benzoic  acid,  87.  Lactic  acid, 
87.  Oxalic  acid,  88.  Palmitic  acid,  89.  Kreatinin,  89. 
Phosphates,  90.  Phosphorus  unoxidised,  96.  Sulphates,  99. 
Sulphur  unoxidised,   99.     Chlorides,  100.      Abnormal  cunsli- 


CONTENTS. 

tuenls.  Serum  albumin,  101.  Paraglobulin,  107.  Modified 
albumins,  108.  Peptones,  108.  Hemi  -  albumose,  111. 
Bile,  112,  Blood,  115.  Sugar,  119.  Inosite,  126.  Lactose, 
128,  Laevulose,  128.  Alkapton,  129.  Leucin  and  Tyrosin, 
130,  Cystin,  132,  Xanthin,  132.  Deposits  derived  from 
urinary  passages.  Mucus,  134,  Renal  epithelium,  135. 
Mucus  corpuscles,  137.  Pigment  particles,  137.  Pus,  138. 
Casts,  140,  Fatty  matters,  144,  Cholesterin,  146,  Fungi, 
147,  Entozoa,  149,  Deposits  separated  from  urine.  Uric 
acid  and  urates.  Cystin,  Xanthin.  Oxalate  of  lime.  Phos- 
phate of  lime.     Triple  phosphate.     Leucin  and  tyrosin,  151. 


CHAPTEE  III.. 

Diffuse  Inflammation  of  the  Kidney. 

Classification  of  Brighl's  disease,  153.  Causation  of  albuminuria, 
159.  Acute  nephritis,  169.  (Tubal  nephritis,  188.  Glomerulo- 
nephritis, 192).  Chronic  tubal  nephritis,  200,  Chronic  inter- 
stitial nephritis,  218,  Etiological  varieties  of  nephritis,  242. 
Treatment  of  nephritis,  251. 


CHAPTEE  IV. 

Suppurative  Inflammation  of  the  Kidney,  etc. 

Classification,  272,  Pysemic  abscesses  of  the  kidney,  273.  Pyeli- 
tis and  pyo-nephrosis,  275,  Pyelitis  and  pyelo-nephrosis,  282. 
Peri-nephritis,  292.  Specific  conditionsleading  to  suppuration 
of  kidney,  299. 


CONTENTS.  XI 

CHAPTEE    V. 

Degenerations  and   Infiltrations  of  the   Kidney. 

Lardaceous  degeneration,  300.  Cystic  degeneration,  312.  Con- 
genital renal  cysts,  312.  Adult  renal  cysts,  314.  Hydro- 
nephrosis, 316.  Dermoid  cysts,  323.  Fatty  degeneration, 
325.  Parenchymatous  degeneration,  327.  Calcareous  degen- 
eration, 328.  Syphilitic  infiltration,  329.  Scrofulous  infiltration, 
33 1 .     Tubercular  infiltration,  337. 

CHAPTEE  VI. 

New  Growths  in  the  Kidney. 

Cancer,  339.  Sarcoma,  350.  iVIyo-sarcoma,  352.  Adenoma,  353. 
Lymphadenoma,  354.     Fatty  and  fibro-fatty  growths,  354. 

CHAPTEE  VII. 

Parasites  in  the  Kidney. 

Hydatids,  356.  Bilharzia  haematobia,  364.  Filaria  Sanguinis 
Hominis,  370.     Chyluria,  373.     Rare  renal  parasites,  378. 

CHAPTEE  VIII. 

Abnormalities    of  the  Kidney. 

Abnormalities  of  position,  380.  Fixed  malpositions  of  the  kidneys, 
381.  Moveable  kidney,  382.  Abnormalities  in  form  and 
number,  393. 


XU  CONTENTS. 

CHAPTEE  IX. 

Vaeiations  in  the  Amount  of  Urine. 

Diabetes  insipidus  (hydruria  and  polyuria),  396.  Diabetes  melli- 
tus  and  glycosuria,  409.  Suppression  of  urine,  451.  Reten- 
tion of  urine,  455. 

CHAPTEE    X. 

Stone  and  Gravel. 

Origin  of  stone,  460.  Lithuria,  466.  Oxaluria,  476.  Phosplia- 
turia,  489.  Etiology  of  calculous  formations,  501.  Renal 
colic,  517.  Solvent  treatment,  520.  Encystment,  524.  Pre- 
ventive treatment  of  stone,  526. 


CHAPTEE    XI. 

Functional  Albuminuria,  Peptonuria  and  Hemoglobinuria. 

Physiological  albuminuria,  532.  Albuminuria  of  digestion,  535, 
Neurotic  albuminuria,  536.  Toxic  albuminuria,  538.  Pep- 
tonuria, 542.     Paroxysmal  hsemoglobinuria,  542. 

APPENDICES. 

I.  Quantitative  estimation  of  urea,  554;   of  hippui-ic  acid,  555  ;    of 

phosphoric  acid,  555  ;  of  sulphuric  acid,  556  ;  of  hydrochloric 
acid,  557;  of  albumin,  557;  of  sugar,  558. 

II.  Diet  for  Diabetes,  560. 


DISEASES  OF  THE  KIDNEY 

AND 

MORBID  CONDITIONS  OF  THE  URINE. 


CHAPTEE  I. 

Geneeal  SYMPTOMATOLoay  OF  Kidney  Disease. 

When  kidney  disease  exists,  its  presence  is  generally  indi- 
cated by  certain  qualitative  changes  in  the  urine  secreted, 
and  which  in  themselves  are  usually  sufficient  to  enable  us 
to  arrive  pretty  conclusively  at  an  opinion  regarding  the 
nature  of  the  disorder.  In  addition  to  the  altered  charac- 
ter of  the  urinary  secretion,  diseases  of  the  kidney  are 
attended  by  other  symptoms,  partly  objective,  and  partly 
subjective  in  character;  such  as  those  which  relate  to 
painful  sensations  in  the  organs  themselves,  or  depend  on 
alterations  in  their  size  and  position,  or  are  connected  with 
disturbance  of  function  in  other  organs.  These  symptoms, 
though  not  in  themselves  always  sufficient,  in  the  absence 
of  a  careful  clinical  examination  of  the  urine,  to  determine 
the  presence  or  the  nature  of  renal  disease,  not  only 
materially  aid  us  in  coming  to  a  conclusion  that  these 
organs  are  the  seat  of  disease  and  thus  lead  us  to  direct 
our  inquiries  more  specially  in  that  direction,  but  they 
also  enable  us  in  obscure  and  mixed  cases  to  effect  a  differ- 
ential diagnosis,  and  also  to  ascertain  with  a  greater  posi- 
tiveness  the  stage  the  disease  has  reached,  by  a  considera- 
tion of  the  charges  wrought  in  the  body  generally,  than 

B 


"A  DISEASES    OF    THE    KIDNEY. 

could  be  possible  by  a  mere  dependence  on  the  results 
obtained  by  an  examination  of  the  urine.  And  as  in 
conducting  a  clinical  examination  we  always  pass  from 
the  general  to  the  special,  it  will  be  advantageous  to  gain 
an  insight  into  the  nature  of  the  general  symptoms  before 
we  undertake  the  task  of  investigating  those  changes  in 
the  urinary  secretion  attendant  on  diseases  of  the  renal 
organs. 

1.  Fain  is  a  symptom  of  kidney  disease,  which  is 
subject  to  considerable  variation,  both  as  regards  its  site 
and  intensity  ;  for  whilst  there  are  few  diseases  of  the 
kidney  which  are  entirely  unaccompanied  by  uneasy  sen- 
sations in  the  neighbourhood  of  the  organ,  still  pain  is 
undoubtedly  a  more  marked  symptom  in  some  forms  than 
in  others.  Thus,  for  instance,  inflammatory  affections 
of  the  substance  of  the  kidney  may  exist  without  the 
patient  making  any  complaint  of  pain,  even  when  closely 
questioned  on  the  subject ;  at  most  only  a  feeling  of  weight 
or  dragging  in  the  loins.  In  other  cases  the  pain  com- 
plained of  is  so  intense  that  the  patient  is  unable  to  bear 
the  slightest  pressure  over  the  loins  or  flank.  The  same 
variabihty  in  the  degree  of  pain  is  noticeable  when  the 
organ  is  invaded  by  new  growths,  or  becomes  the  seat  of 
calculous  deposit.  (Curnow,  Fath.  Soc.  Trans.,  vol.  xxiv., 
p.  148).  The  explanation  of  the  variability  of  this  symp- 
tom is  that  the  substance  proper  of  the  kidney  is  but 
indifferently  supplied  with  nerves  of  common  sensation, 
whilst  these  are  freely  distributed  over  the  surface  of 
the  capsule,  and  around  the  pelvis  of  the  organ.  Thus 
it  happens  in  inflammatory  affections  of  the  kidney,  unless 
there  is  much  swelling  and  tumification  of  the  substance  of 
the  kidney,  causing  stretching  and  tension  of  the  capsule, 
pain  may  not  be  experienced.     Again  with  renal  calculi,  a 


GENERAL    SYMPTOMATOLOGY.  6 

large  mass  wiiich  gradually  destroys  by  its  pressure  the 
whole  of  the  kidney  substance  may  exist  and  yet  give  rise 
to  little  or  no  pain,  whilst  firmly  imbedded,  whereas  a 
small  fragment  of  gravel  falling  into  the  pelvis  of  the 
kidney  will  excite  the  most  distressing  paroxysms. 

There  are  two  characteristics  of  pain  arising  from  kidney 
disease  which  require  notice,  the  first  is  its  paroxysmal 
character.  This  may  be  accounted  for  by  the  fact  that  the 
kidneys  are  more  or  less  over-laid  by  the  ascending  colon 
on  the  right,  and  the  descending  colon  on  the  left,  and 
pain  is  likely  to  be  occasioned  when  these  portions  of  the 
bowel  become  overloaded  with  fseces,  or  distended  with 
flatus,  and  thus  press  on  a  diseased  kidney ;  as  the  contents 
of  the  colon  are  continually  shifting,  we  can  readily  see 
how  it  is  relief  may  suddenly  follow  intense  pain  in  the 
renal  region.  Another  reason  for  the  paroxysmal  nature 
of  the  pain  in  kidney  disease  is  the  occasional  passage  down 
the  ureter  of  blood  clots,  and  urinary  deposits,  which  give 
rise  to  sharp  and  temporary  colic. 

The  other  character  of  renal  pain  is  that  it  is  often  re- 
flected. Morgagni  was  the  first  to  call  attention  to  this 
fact.  It  most  frequently  occurs  in  cases  of  renal  calculus, 
and  as  this  reflected  pain  is  usually  felt  at  the  neck  of  the 
bladder,  it  happens  that  attention  is  drawn  to  the  bladder 
rather  than  the  kidney.  Sometimes  the  pain  instead  of 
being  reflected  to  the  bladder,  is  felt  in  the  groin,  or  down 
the  spermatic  cord,  or  down  the  inner  side  of  the  thigh. 
Cases  of  persistent  pain  in  the  heel,  or  foot,  are  re- 
corded, which  on  the  urine  being  examined  led  to  the 
discovery  of  pus  and  blood-corpuscles  in  the  urine,  un- 
doubtedly caused  by  the  presence  of  a  calculus  in  the 
kidney  of  the  same  side  as  the  foot  affected. 

Attacks  of  pain  of  neuralgic  character  affecting  the 
region  of  the  kidney  are  not    infrequently  complained 

B  2 


DISEASES    OF    THE    KIDNEY. 


of,  especially  in  persons  who  have  resided  in  malarial 
districts.  In  1878  the  late  Dr.  Murchison  gave  me 
the  particulars  of  a  peculiar  form  of  neurosal  attack 
which  he  designated  as  a  "renal  storm  "  and  which  had 
frequently  occurred  in  a  patient  suffering  from  aortic 
regurgitation.  The  attack  commenced  with  excruciating 
pain  over  the  region  of  the  right  kidney,  exactly  like  renal 
colic,  but  there  was  no  sickness  or  retraction  of  testicle, 
and  the  urine  passed  during  and  after  the  attack  was 
perfectly  normal,  nor  was  there  any  jaundice  or  anything 
to  suggest  the  pain  was  due  to  biliary  calculus,  after  lasting 
some  hours  it  passed  off  as  suddenly  as  it  came  on,  "With 
reference  to  this  case  I  may  mention  the  remarks  made  by 
Dr.  Habershon  [Diseases  of  the  Liver, -p.  13)  with  regard  to  the 
neuralgic  pain  sometimes  met  with  in  organic  disease  of 
the  heart  and  which  is  referred  to  as  being  situated  deeply 
behind  the  first  part  of  the  duodenum.  "  It  is,"  he  says, 
"severe,  almost  like  that  from  gall-stone,  but  it  is  without 
jaundice  or  other  symptoms  of  calculus,  it  is  not  connected 
with  the  stomach,  for  it  is  not  affected  by  food,  but 
paroxysmal  and  recurring  sometimes  with  great  regularity." 
In  1880  a  man,  aged  47,  applied  as  an  out-patient  at  the 
London  Hospital  solely  on  account  of  severe  paroxysmal 
attacks  of  pain,  which,  commencing  at  the  angle  of  the 
epigastric  region  where  it  joins  the  right  hypochondrium, 
passed  downwards  into  the  right  lumbar  region.  No 
disease  of  the  liver  or  kidney  could  be  detected,  and  the 
urine  was  perfectly  normal.  On  examining  the  chest, 
however,  we  found  the  left  ventricle  considerably  hyper- 
trophied,  the  result  of  aortic  regurgitation.  This  case  was 
probably  similar  to  that  mentioned  by  Murchison  and  those 
alluded  to  by  Habershon. 

2.  Enlargements  of  the  Kidney.— Owing  to  their 
situation  at  the  back  of  the  abdominal  cavity,  the  kidneys 


GENEEAX    SYMPTOMATOLOGY.  0 

cannot  be  felt  by  palpation  when  of  ordinary  size ;  or  at 
the  most,  in  thin  subjects  only  the  upper  border  of  the 
right  kidney  in  front  can  be  made  out.  It  is  only  therefore 
when  considerable  enlargement  takes  place  that  a  physical 
examination  of  the  abdomen  can  lead  us  to  form  a  definite 
conclusion.  But  even  when  considerable  enlargement 
exists,  the  difficulty  of  diagnosis  is  great,  not  only  in  deter- 
mining differentially  between  enlargement  of  other  organs 
of  the  abdominal  cavity,  such  as  the  ovary,  the  spleen,  the 
concave  surface  of  the  liver,  &c. ;  but  also  when  the 
tumour  is  correctly  referred  to  the  kidney,  to  distinguish 
the  nature  of  the  disease.  In  order  therefore  to  make  a 
successful  diagnosis  three  points  have  to  be  attended  to. 
(1)  An  accurate  knowledge  of  the  anatomical  relations  of  the 
renal  organs ;  (2)  a  systematic  method  of  conducting  the 
physical  examination  to  which  must  be  added  a  tactile 
skill  acquired  by  constant  practice ;  and  (3)  a  thorough 
consideration  of  the  general  symptoms. 

Anatomical  Relation.  The  kidneys  are  situated  at  the 
back  of  the  abdominal  cavity,  behind  the  peritoneum  from 
which  they  are  separated  by  a  layer  of  cellulo- adipose  tissue. 
They  rest  upon  the  lower  portion  of  the  diaphragm,  on  the 
fascia  covering  the  quadrati  lumborum  and  transversaUs 
muscles  and  towards  then-  inner  side  on  the  psoas  muscles, 
The  left  kidney  as  nearly  as  possible  lies  between  a  line 
drawn  outwards  from  the  level  of  the  11th  dorsal  spine  and 
a  similar  hne  drawn  from  the  level  of  the  2nd  lumbar 
spine,  whilst  the  hilum  corresponds  to  the  level  of  the  1st 
lumbar  spine,  and  is  nearly  two  inches  from  the  middle 
line  of  the  body.  The  right  kidney  is  placed  at  a  slightly 
lower  level  than  the  left,  being  from  half  an  inch  to  three 
quarters  of  an  inch  below  the  hmits  given  above.  The 
anterior  relation  of  the  kidneys  are,  however,  of  the  greatest 
importance  in  diagnosing  renal  tumours,  since  owing  to  the 


DISEASES    OF    THE    KIDNEY. 


Fig.  1. — Anatomical  Eelations  of  the  Kidneys,  by  Mr.  Godlee. 


Stm  Sternum. 

X  Xiphoid  Appendix. 

^\ 

Q  y  Rib  Cartilages. 

10/ 

IV  4tli  Lumbar  Vertebra. 

IC  Iliac  Crest. 

Pa  Psoas. 

II  Iliacus. 


L  Liver  outlined  thus 

St  Stomach    1 

D  Duodenum/         '»  " 

P  Pancreas  „  „ 

Cse  Caecum        \ 

AC  Ascending  1 

Colon 
TC  Transverse  >-    ,,  ,, 

Colon 
DC  Descending 

Colon       / 

j/i   Right  and  Left  Kidneys. 


GENEBAL    SYMPTOMATOLOGY.  7 

solidity  of  the  structures  at  the  posterior  aspect,  the  exist- 
ence of  a  tumour  is  not  so  easily  detected  by  manipulation 
as  by  gentle  pressure  on  the  anterior  or  lateral  surface. 
Moreover  a  solid  tumour  occupying  the  loins  and  flank  may 
be  generally  referred  to  the  kidney,  but  when  it  comes  to 
the  front  we  have  to  take  into  consideration  the  possi- 
bility of  its  being  caused  by  enlargement  of  other  organs. 
The  kidney  on  each  side  occupies  a  part  of  the  hypochon- 
driac, epigastric,  umbilical,  and  lumbar  regions  as  shown 
in  fig.  1.  The  right  kidney,  which,  as  stated  above,  natur- 
ally lies  at  a  lower  level  than  the  left,  has  its  lower  border 
corresponding  to  a  line  drawn  just  above  the  upper  level  of 
the  iimbihcus,  whilst  the  left  is  about  half  an  inch  higher. 
The  upper  border  of  the  inner  edge  of  the  right  kidney 
also  extends  rather  more  into  the  umbilical  region  towards 
the  middle  line  than  does  the  left.  The  right  kidney  is  in 
relation  by  its  upper  border  with  the  supra-renal  capsule 
and  the  under  surface  of  the  right  lobe  of  the  liver.  The 
ascending  colon  covers  the  anterior  surface,  whilst  the 
caecum  just  lies  below  the  lower  border.  The  inner  border 
at  its  upper  end  is  just  covered  by  the  duodenum  and  head 
of  the  pancreas.  The  left  kidney  at  its  upper  border  is  in 
contact  with  the  supra-renal  capsule  and  the  spleen.  Its 
anterior  surface  is  covered  at  the  upper  end  by  the  tail  of 
the  pancreas  which  intervenes  between  it  and  the  lower 
border  of  the  stomach,  whilst  the  middle  and  lower  portion 
of  its  surface  is  covered  by  the  descending  colon,  which 
however  it  must  be  remembered  crosses  it  rather  obliquely 
from  above  downwards,  and  from  without  inwards.  This 
is  important  for  in  large  renal  tumours  of  the  left  side,  the 
descending  colon  is  to  be  felt  crossing  rather  than  covering 
the  kidney. 

The  manner  of  examining  for  enlargement  of  the 
kidney  is  as  follows,  the  patient  being  in  bed  or  on  a 
sofa,  has  his  knees  well  drawn  up  so  as  to  flex  the  thighs 


8  DISEASES    OF    THE    KIDNEY. 

upon  the  trunk.  If  the  tumour  is  on  the  right  side,  the 
left  hand  is  to  be  passed  along  the  margin  of  the  false  ribs 
till  it  reaches  the  space  between  them  and  the  crest  of  the 
ilium ;  then  with  the  right  hand  the  wall  of  the  abdomen 
is  to  be  greatly  depressed,  and  the  intestine  pushed  aside, 
by  the  tips  of  the  fingers,  as  much  as  possible.  When  the 
right  hand  is  well  over  the  anterior  kidney  region,  pressure 
is  made  in  the  loins  by  the  fingers  of  the  left  hand  so  as  to 
push  the  kidney  as  far  forwards  as  possible  against  the 
right  hand.  In  this  way  an  enlarged  kidney  can  usually 
be  diagnosed,  but  if  any  doubt  exists,  a  reference  to  the 
general  symptoms  will  as  a  rule  determine  the  point  satis- 
factorily. Thus  for  instance,  the  mobility  of  the  tumour 
on  deep  inspiration,  the  presence  or  absence  of  abnormal 
conditions  of  the  urine,  &c. 

The  following  points  should  be  borne  in  mind  in  distin- 
guishing renal  tumours  from  enlargements  of  other  organs. 

(1)  From  Enlargements  of  the  Liver ;  by  the  tumour  being 
more  or  less  covered  by  intestine ;  by  the  relation  of  the 
tumour  to  the  ribs,  which  instead  of  passing  under  them, 
dips  down  as  it  were  so  that  the  fingers  can  be  placed 
between  their  margin  and  the  tumour  that  the  tumour  is 
not  affected  by  the  ordinary  movements  of  respnation ; 
that  there  is  generally  some  marked  morbid  condition  of 
the  urine ;  that  the  enlargement  is  not  accompanied  with 
jaundice. 

(2)  From  Enlargements  of  the  Ccecum  or  Colon;  by  the 
absence  of  any 'special  intestinal  disturbance;  that  it  does 
not  disappear  after  the  employment  of  purgatives.  A 
perinephritic  abscess  is  distinguished  from  a  fjecal  abscess, 
by  its  more  rounded  and  oval  form,  by  its  deeper  situation, 
by  the  frequent  occurrence  of  an  oedematous  condition  of 
the  skin  in  the  region  of  the  loins,  by  a  lower  degree  of 
fever  and  with  more  marked  remissions. 


GENEKAL    SYMPTOMATOLOG"S .  9 

(3)  From  Enlarged  Spleen ;  by  the  tumour  being  more 
rounded  than  a  splenic  enlargement,  which  often  presents 
a  defined  edge  which  is  notched.  By  not  projecting  so  far 
forward  anteriorly  as  a  splenic  tumour  does ;  by  being 
covered  more  or  less  by  the  transverse  colon  ;  by  its  not 
being  influenced  by  the  respiratory  movements. 

(4)  From  Ovarian  Tumours;  the  history  points  to  the 
enlargement  having  first  commenced  in  the  lumbar  region  ; 
by  the  tumour  being  felt  in  the  loin  as  well  as  in  front ;  by 
the  colon  more  or  less  covering  the  tumour,  by  the  nega- 
tive information  gained  by  vaginal  examination. 

As  a  general  rule  renal  tumours  are  usually  most  pro- 
minent in  the  back  and  flank,  but  instances  do  occur  where 
the  enlargement  is  directed  more  towards  the  anterior 
wall  of  the  abdomen,  increasing  however  always  from 
behind  forwards.  This  variation  in  situation  depends  of 
of  course  on  the  part  of  the  kidney  affected  and  the  nature 
of  the  disease.  Thus  in  perinephritis,  or  enlargement  of 
the  kidney  from  numerous  cysts,  the  tumour  will  be  found 
distinctly  occupying  the  loins,  whilst  in  rapidly  growing 
fungoid  disease  or  collections  of  pus  within  the  cavity  of 
the  kidney,  the  enlargement  may  often  be  best  felt  between 
the  ribs  and  the  median  line  above  the  umbihcus.  These 
points  however  will  call  for  special  attention  when  each 
special  form  of  renal  tumour,  and  its  differential  diagnosis 
is  dealt  with. 

3.  Derangements  of  the  Circulatory  System. — In 
those  affections  of  the  kidney  known  collectively  as  Bright's 
■  disease,  marked  changes  occur  in  the  cu'culatory  system, 
which  by  their  results  at  once  draw  attention  to  the  morbid 
processes  going  on  in  the  renal  organs.  These  are  dropsy, 
pulse  of  high  tension,  hypertrophy  of  the  left  ventricle, 
and  haemorrhages  from  mucous  surfaces.  These  condi- 
tions however  are  not  combined  in  every  form  of  Bright's 


10 


DISEASES    OF    THE    KIDNEY. 


disease.  Thus  dropsy  is  the  special  cHnical  feature  of  the 
inflammation  of  the  kidney  which  eventuates  in  the  large 
white  kidney ;  whilst  a  pulse  of  high  tension,  with  hyper- 
trophy of  the  left  ventricle  is  characteristic  of  the  granular 
and  contracted  kidney.  There  are  exceptions,  it  is  true,  to 
this  general  statement,  for  a  slight  degree  of  dropsy  is 
often  noticeable  towards  the  end  in  cases  of  granular  kid- 
ney, when  the  hypertrophied  ventricle  at  last  becomes 
weakened,  and  the  blood  pressure  throughout  the  systemic 
system  falls  from  its  previous  high  tension.  On  the  other 
hand,  high  tension  of  pulse,  and  a  certain  degree  of  hyper- 
trophy of  the  left  ventricle,  is  undoubtedly  observed  in 
those  cases  in  which  a  white  large  kidney  has  become  con- 
tracted (small  pale  granular  kidney).  Still  the  fact  re- 
mains that  dropsy  is  characteristic  of  the  inflammatory 
form,  and  a  pulse  of  high  tension  and  hypertrophy  of  the 
left  ventricle  of  the  more  purely  chronic  variety.  The  rea- 
sons for  this  as  well  as  the  occasional  exception  will  now 
be  discussed. 

(1)  Drojysy. — Text-books  on  medicine  tell  us  that  when- 
ever the  balance  between  the  two  processes,  transfusion 
of  the  nutritive  plasma  from  the  blood-vessels  and  its 
re-absorption  by  the  lymphatics  and  veins,  is  disturbed, 
the  quantity  of  fluid,  which  is  always  present  in  small 
quantity  in  the  tissues,  becomes  increased,  and  thus  leads 
to  dropsical  accumulations.  It  is  thus  manifest  that 
dropsy  may  be  referred  either  to  pressure  in  the  arterial 
system,  or  to  obstruction  of  the  venous  circulation.  The 
typical  form  of  a  dropsical  accumulation  due  to  venous 
obstruction,  is  of  course  that  which  follows  on  cirrhosis  of 
liver,  when  the  radicles  of  the  portal  venous  circulation  are 
compressed  by  the  contraction  of  the  connective  tissue 
elements  surrounding  the  lobules.  In  heart  disease, 
especially  of  the  mitral  valve,  and  of  the  right  side  of  the 


GENERAL    SYMPTOMATOLOGY. 


11 


heart,  the  dropsy  in  the  first  instance  is  due  to  venous 
congestion,  brought  about  by  the  impeded  return  of  blood 
to  the  right  side  of  the  heart  by  the  inferior  vena  cava, 
and  this  almost  invariably  commences  about  the  ankles 
and  feet.  Though  as  the  kidneys  become  affected,  as  they 
do  in  all  protracted  cases  of  valvular  disease  of  the  heart, 
the  dropsy  assumes  the  form  due  to  increase  of  arterial 
pressure.  The  dropsy  then  of  cardiac  and  hepatic  disease, 
because  it  affects  the  particular  branch  of  the  venous 
system  which  is  obstructed,  is  essentially  a  local  dropsy, 
whilst  as  we  shall  now  see,  the  dropsy  resulting  from 
kidney  disease  is  a  general  effusion.  This  is  brought 
about  in  the  following  way.  In  that  form  of  kidney  disease 
which  is  generally  accompanied  by  dropsy,  the  secretion  of 
water  by  the  kidneys  is  lessened  considerably,  whilst  the 
quantity  of  water  ingested  to  supply  the  needs  of  the  body 
remains  the  same,  consequently  the  volume  of  blood  in  the 
arterial  system  is  increased,  so  that  the  serum  passes  into 
the  tissues  in  consequence  of  this  increased  pressure, 
whilst  no  doubt  its  poorness  in  albuminous  constituents, 
owing  to  the  withdrawal  of  these  substances  from  the 
blood  by  the  urine,  renders  its  passage  through  the  walls 
of  the  vessels  more  easy.  This  makes  plaia  what  was 
previously  stated,  that  general  dropsy  distinguishes  the 
acute  forms  of  Bright's  disease  from  the  more  chronic. 
For  in  the  acute  form  the  amount  of  urine  secreted  is  con- 
siderably diminished,  whilst  in  the  latter  owing  to  the  high 
arterial  tension,  as  manifested  by  the  pulse  and  the  hyper- 
trophied  condition  of  the  left  ventricle,  the  urinary  secre- 
tion is  abundant  and  even  copious.  As  soon  however  as 
the  left  ventricle  ceases  to  increase  and  its  tissue  to  un- 
dergo degenerative  changes,  then  the  amount  of  urine 
diminishes  and  a  certain  amount  of  dropsy  occurs,  though 
never  to  such  an  extent  as  is  observable  in  the  early  stages 


12  DISEASES    OF    THE    KIDNEY. 

of  tlie  inflammatory  form.  Thus  general  dropsy  becomes 
a  distinct  feature  of  acute  and  sub-acute  nephritis,  whUst 
it  is  comparatively  a  rare  event  in  chronic  interstitial 
nephritis. 

Thus,  according  to  a  statement  of  Dr.  George  Johnson, 
in  twenty- six  cases  of  the  large  white  kidney,  dropsy  was 
found  in  twenty-four,  while  in  thnty-three  cases  of  con- 
tracted kidney,  dropsy  was  observed  only  in  fourteen  cases. 
In  speaking  however  of  general  dropsy  as  being  thus 
symptomatic  of  one  form  of  Bright's  disease,  the  student 
must  be  warned  against  taking  the  presence  of  general 
dropsy  as  conclusive  of  primary,  or  even  of  disease  of  the 
kidneys  at  all.  In  speaking  of  the  dropsy  of  heart  disease, 
it  was  pointed  out  that  at  first  it  was  due  to  venous  con- 
gestion, and  that  it  was  only  when  the  kidneys  became 
affected,  and  began  to  undergo  atrophic  changes,  that  the 
oedema  became  general.  Here  the  history  of  the  case 
would  help  us  to  arrive  at  a  right  conclusion,  for  if  the 
(Dedema  began  at  the  legs  and  then  became  general,  we 
should  have  no  hesitation  in  saying  that  the  cardiac  was 
the  primary,  and  the  renal  the  secondary  lesion.  Again 
in  certain  cases  of  tricuspid  regurgitation  we  may  be 
misled  especially  when  the  venous  circulation  in  the 
neck  is  much  affected,  so  that  coincident  with  the  swell- 
ing of  the  legs  the  eyelids  become  puffy.  A  httle  dis- 
crimination will  show  however  that  there  is .  no  pufifing 
of  the  trunk,  nor  do  the  hands  swell,  whilst  albumin 
will  be  probably  absent  from  the  urine.  In  one  case, 
however,  I  have  seen  the  whole  body,  face,  trunk,  and 
limbs  enormously  swollen,  and  yet  the  kidneys  were 
healthy.  In  this  case  a  large  aortic  aneurism  so  pressed 
on  the  right  auricle,  as  greatly  to  retard  the  blood  flowing 
through  the  superior  as  well  as  the  inferior  cava.  Media- 
astinal  tumours  might  produce  a  similar  effect,  but  such 


GENEBAL    SYMPTOMATOLOGY.  13 

cases  as  these  are  rarities,  whilst  the  evidence  of  the  exist- 
ence of  a  large  intra-thoracic  growth  would  lead  one  to 
suspect  compression  of  the  cava,  and  hence  that  the  dropsy 
was  due  to  venous  congestion  than  to  increase  of  the 
arterial  pressure.  Cases  of  myxoedema  may  be  mistaken  for 
general  dropsy,  they  can  however  be  distinguished  by  the 
firmer  character  of  the  oedema,  the  peculiar  mental  slug- 
gishness, the  muscular  slowness  of  movement,  the  spade 
like  enlargement  of  the  hand,  and  the  absence,  or  if 
present,  only  of  a  small  trace,  of  albumin  in  the  urine, 
which  characterise  them. 

Eenal  dropsy  may  set  in  suddenly  in  the  course  of  ne- 
phritis. This  most  commonly  happens  in  the  acute  form, 
though  it  not  infrequently  occurs  that  patients,  who  are 
suffering  from  the  chronic  variety  and  who  have  previously 
only  exhibited  a  shght  puffiness,  will  become  suddenly  and 
extremely  swollen  after  exposure  to  cold.  As  a  rule,  how- 
ever, it  comes  on  more  gradually  and  does  not  at  first  attract 
the  patient's  attention,  and  is  perhaps  first  discovered 
by  the  physician  who  on  examining  the  patient  finds  the 
pressure  of  the  stethoscope  gives  rise  to  decided  pitting. 
Or  what  very  commonly  happens  is  that  patients  come  to 
us,  complaining  that  when  they  wake  in  the  morning  their 
eyelids  are  partially  closed,  or  the  hand  on  the  side  they 
have  been  lying  is  swollen.  From  this  slight  oedema  to  an 
extreme  condition  of  anasarca  the  gradation  is  variable. 
It  is  rare,  however,  for  effusion  into  the  serous  cavities  to 
occur  during  the  early  stages,  unless  the  patient  has  been 
exposed  to  cold,  though  in  prolonged  cases  it  happens 
sooner  or  later  as  a  natural  sequence.  When  that  some- 
what rare  event  oedema  of  the  glottis  occurs,  it  is  generally 
attributable  to  exposure  to  severe  cold,  and  then  it  may 
come  on  in  quite  an  early  stage.  When  the  renal  disease 
shows  signs  of  amendment,  either  when  acute  by  a  ten- 


14  DISEASES    OF    THE    KIDNEY. 

dency  to  recovery  ;  or  in  the  chronic  form  by  amehoration 
under  treatment,  or  from  the  increased  tension  in  the 
vessels  from  commencing  hyper-trophy  of  the  left  ventricle, 
the  first  symptom  is  an  increased  flow  of  urine,  and  this 
speedily  followed  by  a  corresponding  decrease  of  the  general 
anasarca.  Indeed  patients  are  often  alarmed  at  the  pro- 
digious diuresis,  and  rapid  disappearance  of  their  swelling, 
imagining  that  their  disease  has  taken  an  unfavourable 
turn.  Often  considerable  relief  to  the  dropsical  distension 
is  afforded  by  spontaneous  diarrhoea,  a  method  of  relief 
the  physician  endeavours  to  encourage  by  the  administra- 
tion of  hydragogue  medicine,  but  which  nevertheless  should 
be  administered  with  caution  in  the  chronic  form  of  the 
disease,  when  the  patient  is  weakened  by  a  long  continued 
disease,  the  diarrhoea  in  these  cases  being  sometimes  in- 
controllable. 

With  regard  to  the  chemical  qualities  of  the  transuded 
fluid,  it  will  be  plain  from  what  has  been  said  of  the 
causes  of  dropsy,  that  it  consists  of  blood  serum  more 
or  less  dUute,  the  degree  of  dilution  being  in  direct  propor- 
tion with  the  degree  of  hydr^emia  and  the  loss  of  albumin. 
Thus  if  we  take  the  specific  gravity  of  normal  blood  serum 
at  l*025-28,  we  find  the  specific  gravity  of  dropsical  fluid 
ranges  form  I'OOS  to  1'020  according  to  the  amount  of 
solid  matter  present.  The  proteids  consist  of  sero- albumin, 
paraglobuhn  and  fibrinogen,  and  range  from  0-4  to  6  per 
cent.  On  standing  sometimes  after  being  withdrawn  from 
the  body,  tine  flakes  of  fibrin  are  deposited.  Urea  is 
generally  present  varying  in  amount  from  extremely 
minute  quantities  to  the  same  percentage  as  that  found  in 
the  urine.  Thus  in  one  interesting  case  where  about  a 
pint  and  a  half  of  anasarcous  fluid  together  with  the 
twenty-four  hours'  urine  passed  by  the  patient,  I  found  the 
percentage  composition  nearly  equal,  so  that  supposing  the 


GENEBAL    SYMPTOMATOLOGY.  15 

fluid  transuded  in  the  body  to  have  been  equal  in  amount 
to  the  twenty- four  hours'  urine,  the  quantity  of  urea  passed 
out  of  the  circulation  into  the  two  fluids  would  nearly  have 
reached  the  normal  excretion,  the  urine  in  this  case  con- 
taining as  it  did  rather  less  than  half  the  normal  amount. 
Traces  of  glucose  are  sometimes  found  in  dropsical  effu- 
sions of  the  peritoneal  cavity.  Serous  effusions  are  like- 
wise distinguished  by  containing  more  albumin  and  sohd 
matter  generally  than  are  found  in  the  exudations  from  the 
subcutaneous  tissue. 

(2)  Cardio -vascular  Changes.  Chronic  renal  affections 
are  usually  associated  with  morbid  changes  in  other  organs 
of  the  body.  But  no  change  is  so  marked  as  that  which 
occurs  in  the  vascular  system  during  the  development  and 
progress  of  the  granular  kidney.  The  changes  particularly 
referred  to,  are  hypertrophy  of  the  left  ventricle,  thickening 
of  the  walls  of  arterioles,  and  atheromatous  conditions  of 
the  arteries. 

On  feeling  the  pulse  of  a  patient  suffering  from  this 
granular  degeneration  of  the  kidneys  we  find  it  tense  and 
bounding — the  high  tension  being  remarkably  persistent, 
the  artery  remaining  full  both  diiring  the  systole  and 
diastole.  On  examining  the  heart,  we  find  its  action 
increased  and  heaving ;  whilst  the  area  of  precordial  dul- 
ness,  if  no  emphysema  of  the  lungs  is  present  to  mask  it, 
is  increased,  the  apex  beat  being  at  the  same  time  displaced 
a  little  outwards  to  the  left.  The  heart  sounds  are  loud, 
and  there  is  often  accentuation  of  the  second  sound  heard 
over  the  aortic  cartilage.  These  conditions  never  fail  to  pre- 
sent themselves  during  the  height,  or  as  it  is  called  the  status 
of  the  disease,  though  during  the  earher  period  they  may 
escape  recognition,  and  in  the  later,  the  active  hypertrophy 
of  the  heart's  muscles  gives  place  to  fatty  degeneration,  so 


16  DISEASES    OF    THE    KIDNEY. 

that  the  heart  sounds  become  soft  and  faint,  and  the  pulse 
feeble  and  compressible. 

The  question  now  arises,  to  what  are  we  to  attribute 
this  pulse  of  high  tension  and  hypertrophy  of  the  left 
ventricle  ? 

According  to  Dr.  George  Johnson,  who  first  drew  attention 
to  the  thickened  condition  of  the  small  arteries  in  chronic 
Bright's  disease  [Medico -Chirurgical  Transactions,  vol.  xxxiii.), 
it  is  due  to  an  impure  state  of  the  blood.  In  consequence, 
he  says,  of  the  degeneration  of  the  kidney,  the  blood  is  mor- 
bidly changed ;  the  minute  arteries  throughout  the  body  re- 
sist the  passage  of  this  abnormal  blood,  containing  as  it  does 
in  excess  urinary  excretory  matter,  and  being  also  deficient 
of  some  of  its  own  normal  constituents.  As  a  consequence 
of  this  resistance,  the  internal  longitudinal  and  the  exter- 
nal circular  muscular  fibres  of  the  small  arteries  are  con- 
siderably increased,  and  the  external  fibrous  coat  of  the 
vessels  is  also  thickened ;  whilst  with  these  changes  the  left 
ventricle  of  the  heart  becomes  simultaneously  hyper- 
trophied. 

Sir  W.  GruU  and  Dr.  Sutton  on  the  other  hand  maintain 
{Medico- Chirurgical  Transactions, 'vol.  Iv.),  that  the  thicken- 
ing is  due  to  a  "  hyalin-fibroid  "  formation  in  the  walls  of 
the  minute  arteries  throughout  the  body,  and  a  hyalin- 
granular  change  in  the  corresponding  capillaries ;  that  this 
change  occurs  chiefly  outside  the  muscular  layer,  but  also 
in  the  tunica  intima  of  some  arterioles,  whilst  the  muscular 
layer  of  the  affected  vessels  is  often  atrophied  in  a  variable 
degree.  They  also  maintain  that  the  kidney  disease  does 
not  give  rise  to  this  vascular  change,  since  whilst  it  may 
be  found  in  cases  when  the  kidney  is  much  contracted,  it 
may  be  met  with  in  kidneys  but  little  affected,  and  even 
healthy.  They  therefore  hold  that  these  changes  are  due 
to  a  general  morbid  state,  and  are  the  primary  and  essen- 


GENERAL    SYMPTOMATOLOGY. 


17 


tial  condition,  when  found  co-existing  with  granular  kid- 
ney, though  extensive  degeneration  of  the  kidney,  may 
occur  without  their  development.  They  also  exi^lain  the 
cardiac  hypertrophy  as  arising  from  the  impediment 
caused  by  the  diminished  elasticity  of  the  arterial  walls, 
from  the  deposition  of  this  "  hyalin-fibroid  "  material  in 
their  walls,  the  heart  having  to  contract  with  greater 
force  to  carry  on  the  circulation. 

It  will  be  seen  from  the  foregoing  statement  that  the 
points  in  dispute  are  sharply  defined.  Dr.  Johnson 
maintaining  that  the  change  in  the  small  arteries 
and  the  left  ventricle  are  simultaneous,  and  are  a 
secondary  consequence  to  the  renal  obstruction.  "Whilst 
Sir  W.  Gull  and  Dr.  Sutton  contend  that  the  thickening 
of  the  arterioles  is  due,  not  to  muscular  hypertrophy, 
but  to  "  hyalin-fibroid "  formation  in  their  walls,  and 
that  the  hypertrophy  of  the  heart,  is  not  simulta- 
neous with  the  change  in  the  vessels  but  consequent 
upon  them,  whilst  these  changes  are  primary  to  the  mor- 
bid state  of  the   kidney.      It  is   difficult  to   harmonize 


Pig.    2.— Thickened  Arteries   from    Granular   Kidneys,      (a)  Longitu- 
dinal, (6)  Transverse  Sections  (Green's  Patkology). 


views  so  directly  opposite  as  to  questions  of  fact.     With 

c 


18  DISEASES    OF    THE    KIDNEY. 

regard  to  the  thickening  of  vessels,  subsequent  observers 
have  confirmed  the  statement  of  both  parties,  and  have 
described  the  hypertrophy  of  the  circular  and  longitudinal 
fibres  as  seen  by  Johnson,  as  well  as  the  hyalin-fibroid 
changes    described  by   Gull   and   Sutton.       Indeed  Dr. 
Saundby  in  a  valuable  communication  (Pai^oZo^icaZ  Society's 
Transactions,  Vol.  XXXI),  has  shown  that  in  two  vessels 
taken  from  the  same  kidney,  one  had  well  marked  fibroid 
changes,  with  little  or  no  hypertrophy,  in  its  walls,  whilst 
the  other  was  almost  entirely  made  up  of  muscular  fibres  ; 
"near  the  inner  margin,  however,  some  fibres  of  elastic 
tissue  were  recognised,  and  some  of  the  cells  in  the  neigh- 
bourhood were   more  like  connective  spindle  cells,  than 
muscular  fibres,  whilst  a  few  were  round  and  oval,  sug- 
gestive of  the   probability  of  a  transition  taking  place." 
Dr.  Saundby  thinks  that  Gull  and  Sutton  only  err  in  deny- 
ing the  existence  of  the  hypertrophy  of  the  muscular  coat, 
which  though  not  constant  is  quite  common,  and  he  also 
thinks  that  some  of  their  drawings  were  made  from  vessels 
like  the  second  one  described,  but  that  owing  to  some  im- 
perfections in  their  histological  manipulation   they   gave 
only  blurred  and  indistinct  features  to  the  structures  repre- 
sented.     Concurring   entirely  with  Dr.  Saundby  in  this 
matter,  I  think  that  the  relative  proportion  in  which  the 
two  conditions  will  be  observed,  will  be  found  to  depend 
on  closer  examination  on  the  stage  of  the  disease  and  its 
character.      With  regard  to  the  part  relatively  played  by 
hypertrophy  and  the  fibroid- hyaline  substance,  I  venture 
to  think  that  the  muscular  elements  will  be  found  in  ex- 
cess during  the  early  progress  of  the  disease  and  at  its 
height,  and  that  the  fibroid  changes  will  be  found  in  cases 
of  longer  standing,  since  we  know  that  long  continued 
arterial  tension  is  favourable  to  the  development  of  fibroid 
changes,  and  these  probably  when  they  supervene,  replace 
or  obliterate  the  muscular  elements. 


GENEBAL    SYMPTOMA-TOLOGY.  19 

These  car dio -vascular  changes  are  observed  in  both 
forms  of  granular  kidney,  the  pale  and  the  red,  but 
they  develope  in  a  different  manner  in  each ;  (a) 
in  the  pale  granular  kidney,  the  result  of  acute  or 
sub-acute  inflammation,  they  are  not  observed  in  the 
early  stage,  "whilst  the  kidneys  are  still  large  and  toler- 
ably smooth,  but  they  gradually  develope  as  the  pro- 
cess of  contraction  goes  on,  though  6ven  in  advanced 
stages  the  cardiac  hypertrophy  and  vascular  tension 
rarely  reaches  the  high  grade  observable,  often  at  a  very 
early  period,  in  red  granular  kidney.  In  the  pale  granular 
kidney  the  vascular  changes  are  brought  about  in  the  fol- 
lowing vyay,  whilst  the  kidneys  are  still  large  and  smooth, 
the  quantity  of  water  eliminated  by  them  is  extremely 
scanty,  consequently,  if  the  same  amount  of  water  be  in- 
gested daily,  the  volume  of  blood  in  the  system  is  increased 
and  the  arterial  pressure  augmented  throughout  the  body. 
In  order  to  secure  a  sufficient  secretion  of  urine,  increased 
cardiac  force  is  required.  This  is  often  not  sufficient,  and 
the  over  distended  vessels  relieve  themselves  by  exuding 
their  aqueous  serum  into  the  tissues  (dropsy),  a  condi- 
tion which  varies  inversely  with  the  amount  of  urine 
secreted.  For  if  by  means  of  digitalis  we  supply  the  defi- 
cient cardiac  power,  and  by  diuretics  stimulate  the  renal 
function,  the  dropsy  diminishes  pan  passu  with  the  in- 
creased flow  of  urine.  The  good  effects  resulting  from  the 
administration  of  digitalis  in  these  cases  point  strongly  to 
the  fact,  that  increased  cardiac  action  is  required,  and 
which  nature  under  favourable  conditions  herself  supplies. 
For  as  these  cases  progress  we  find  after  a  time  the  area 
of  cardiac  dulness  increasing,  the  pulse  acquiring  a  higher 
degree  of  tension,  the  excretion  of  urine  becoming  more 
copious,  whilst  the  tendency  to  dropsy  diminishes.  In  this 
form  of  chronic  Bright's  disease,  then,  I  think  the  cardio- 

C   2 


20  DISEASES    OF    THE    KIDNEY. 

vascular  changes  may  be  said  to  fairly  follow  on  the  disease 
of  the  kidney,  and  are  not  due  to  a  general  morbid  state,  they 
however  never  attain  a  very  high  grade  in  this  form  of 
contracting  kidney. 

(b)  But  with  the  case  of  the  typical  small  red  gra- 
nular kidney  the  case  is  very  different.  Here  at  the 
very  onset  apparently,  we  meet  with  considerable  hyper- 
trophy of  the  left  ventricle  and  a  hard  tense  pulse, 
sometimes  without  any  material  change  in  the  urinary 
secretion  to  lead  us  to  suppose  there  is  anything  amiss 
with  the  kidneys,  although  in  the  generality  of  cases  there 
is  increased  secretion,  and  a  trace  of  albumin,  but  the  lat- 
ter is  not  infrequently  absent  at  an  early  period,  and  the 
only  symptoms  we  have  often  for  months,  is  powerful  car- 
diac action,  hard  pulse,  and  an  abundant  secretion  of 
urine.  As  the  case  goes  on,  we  find  albumin  appears,  some- 
times intermittently  if  not  present  before,  and  increasing 
if  it  has  been,  hyalin  casts  begin  to  make  their  appearance 
and  then  we  recognise  the  full  character  of  the  renal 
affection.  But  there  is  also  another  point,  these  patients 
at  quite  an  early  period,  sometimes  before  the  full  develop- 
ment of  the  renal  symptoms,  at  all  events  as  soon  as 
they  are  observed,  are  generally  found  to  be  the  sub- 
jects of  extensive  atheromatous  degeneration.  Now  it 
can  hardly  be  argued,  that  all  these  vascular  changes 
are  the  result  of  the  disease  in  the  kidneys,  and  are 
caused  by  the  retention  in  the  blood  of  urinary  matters 
that  ought  to  be  eliminated.  For  even  if  we  admit  that 
cardiac  hypertrophy  and  arterial  tension  are  but  rarely 
noticed  before  the  renal  changes  make  themselves  mani- 
fest, we  cannot  with  the  evidence  before  us  hesitate  in 
coming  to  the  conclusion  that  they  run  at  least  a  simul- 
taneous course,  and  that  the  cardio-vascular  changes  asso- 
ciated with  the  typical  red  granular  kidney,  are  due  to  a 


GENERAL    SYMPTOMATOLOGY.  21 

general  morbid  state  which  is  the  primary  and  essential 
condition.  With  regard  to  the  nature  of  the  morbid  state 
that  induces  these  changes  in  the  vessels  and  in  the  kid- 
neys, they  may  I  think  be  referred  to  one  or  other  of  the 
following  conditions  either  singly  or  combined,  (a)  In- 
creased tissue  metabolism  or  long  continued  over  stimulation, 
from  the  ingestion  of  a  highly  nitrogenised  diet,  or  the 
excessive  use  of  alcohol.  (h)  Toxic  agencies  as  caused 
by  gout  or  rheumatism,  either  hereditary  or  acquired,  or 
by  an  extraneous  poison  such  as  lead,  (c)  Nervous  in- 
fluences, these  may  act  by  leading  to  early  textural  decay 
by  direct  influence,  as  from  the  exhaustion  caused  by 
over-work,  anxiety,  etc.  They  may  be  also  of  a  reflex 
character,  chronic  irritation  of  the  kidney  structure  leading 
to  cardio-vascular  hypertrophy.  This  supposition  is  the 
more  probable  since  Dr.  Dickinson,  and  subsequently  others, 
observed  cardio-vascular  changes  to  occur  under  the  irrita- 
tion produced  by  the  presence  of  renal  calcuh,  and  it  is 
not  improbable  that  the  irritation  caused  by  the  long  con- 
tinued secretion  of  highly  acid  urine,  may  have  the  same 
effect  (see  Gouty  Nephritis). 

In  addition  to  the  above  mentioned  changes  in  the 
heart  and  vessels  in  granular  disease  of  the  kidney,  chronic 
arterial  inflammation  leading  to  an  atheromatous  condition 
of  the  vessels,  is  to  be  constantly  observed.  The  causes 
that  produce  it  are,  as  Dr.  Moxon  has  stated,  due  to 
the  increased  strain  thrown  on  the  vessels  by  the  long 
continued  arterial  tension,  thoiigh  perhaps  in  some  mea- 
sure aided  by  the  impaired  condition  of  nutrition  generally. 
Owing  to  this  arterial  degeneration,  accompanied  by  the 
forcible  action  of  the  hyper trophied  left  ventricle,  hemor- 
rhages are  of  frequent  occurrence,  hence  cerebral  apoplexy 
is  a  common  termination  of  a  case  of  granular  disease  of 
the   kidney;    whilst   hsemorrhages   of  a   less   formidable 


22  DISEASES    OF    THE    KIDNEY. 

nature,  as  epistaxis,  hffimorrliage  into  the  retina,  from 
bowels  and  lungs,  and  ecclaymoses  under  the  skin  are  of 
frequent  occurrence.  Wlien  haemorrhages  occur  to  any 
extent  and  are  repeated  at  frequent  intervals,  the  prog- 
nosis becomes  very  grave  indeed,  but  I  cannot  agree  with 
the  statement  of  Bartel,  that  every  case  of  well  esta- 
blished hsemorrhagic  cachexia  does  not  survive  more  than 
a  few  weeks  after  the  commencement  of  the  bleedings.  I 
have  known  patients  with  granular  kidneys  survive  for  a 
considerable  period  after  severe  and  repeated  epistaxis ; 
and  even  after  an  extensive  cerebral  hemorrhage,  their 
lives  being  prolonged  by  the  enforcement  of  almost  abso- 
lute rest,  and  the  employment  of  a  non-nitrogenous  diet 
and  complete  abstinence  from  alcohol. 

A  reference  to  the  derangements  of  the  circulation 
in  diseases  of  the  kidney  would  not  be  complete  without 
an  allusion  to  the  vascular  condition  which,  according  to 
Dr.  Pavy,  is  the  key  to  the  explanation  of  the  saccharine 
condition  of  the  urine  in  diabetes.  Dr.  Pavy  is  of 
opinion  that  diabetes  is  due  to  a  failure  of  the  assimu- 
lative  function  of  the  liver,  which  instead  of  storing 
up  glycogen,  allows  it  to  pass  off  as  sugar  to  the  blood. 
He  has  shown  that  venous  blood  is  favourable,  and  oxy- 
genated blood  is  unfavourable  to  the  storing  up  of  glycogen. 
Now  no  organ  in  the  body  is  supplied  with  venous  blood 
in  like  manner  to  the  liver,  so,  in  correspondence,  nowhere 
does  glycogen  exist  to  a  like  extent.  But  under  circum- 
stances of  vaso-motor  paralysis,  affecting  the  vessels  of  the 
chylo-poietic  viscera,  blood  unduly  charged  with  oxygen 
sometimes  reaches  the  liver  by  the  portal  vein,  thus  induc- 
ing glycosuria.  In  confirmed  cases  of  diabetes  the  vaso- 
motor paralysis  may  be  general,  and  Dr.  Pavy  points  to 
the  bright  red  appearance  of  the  tongue,  so  often  noticed  in 
severe  cases  of  diabetes,  as  an  evidence  of  this  hypersemic 


GENERAL    SYMPTOMATOLOGY.  23 

condition,  the  idea  suggesting  itself  that  the  blood  is  flow- 
ing through  the  organ  without  being  properly  deprived  of 
its  arterial  character.  The  pecnhar  florid  injection  of  the 
capiUary  vessels  of  the  face,  sometimes  observed  m  severe 
cases  of  diabetes,  is  probably  due  to  the  same  cause. 

4  Derangements  of  the  Nervous  System- 
Many  symptoms  indicative  of  disturbance  of  innervation 
manifest  themselves  in  relation  to  both  acute  and  chronic 
diseases  of  the  kidneys,  and  which  may  be  considered 
as  belonging  to  either  of  the  three  following  conditions, 
uremia,  acetonsemia,  neuralgia. 

(1)  Urmiia  is  a  clinical  collective  name  used  to  describe 
very  various  functional  disorders  of  the  nervous  system 
which  are  sometimes  acute  and  sometimes  chronic. 

Acute  UrcBmic  attacks  may  occur  in  the  chronic  stage  ot 
Bright's  disease  as  well  as  in  the  acute.     Then:  character- 
istic features  are   powerful  epileptiform  convulsions  and 
coma.     As  a  general  rule  the  attacks  commence  with  a 
series  of  epileptic  fits  quickly  succeeding  each  other,  and 
as  these  pass  off  a  comatose  condition  succeeds..    In  others 
the  attack  is  ushered  in  by  a  violent  single  convulsion 
which  in  some  cases  is  followed  by  a  noisy  dehnum  which 
after  lasting  some  hours  suddenly  passes  into  a  profound 
coma.    Cases  occasionally  occur,  however,  in  which  tlie  pa- 
tient passes  into  deep  coma  without  its  being  preceded  by 
convulsions.     Acute  uremic  attacks  may  come  on  suddenly 
without  warning  but  generally  there  is  some  previous  mdica- 
tion  of  the  coming  storm.    The  patient  complams  of  head- 
ache  ;  the  pulse  often  becomes  remarkably  retarded  :  there 
is  dimness  of  vision  perhaps  temporary  blindness  {urmmc 
amaurosis),  without  any  ophthalmoscopic  indications  and 
which  passes  off  as  quickly  as  it  comes  on.     If  the  urine 
has  been  examined  daily  we  find  shortly  before  the  attack 
that  the  quantity  secreted  is  considerably  diminished  as  is 


24  DISEASES    OF    THE    KIDNEY. 

also  the  amount  of  solid  matter  excreted.  In  tlie  attack 
itself  in  addition  to  the  rapidly  recurring  convulsive  sei- 
zures, we  find  that  sensibility  is  diminished,  whilst  reflex 
irritability  is  increased,  the  pulse  previously  retarded  be- 
comes small  and  very  rapid,  the  temperature  rises  to  a 
considerable  degree,  even  occasionally  to  hyperpyrexia. 
In  the  coma  there  are  occasional  convulsive  movements 
and  twitchings,  the  teeth  are  ground,  and  the  faeces,  and 
the  urine  if  the  latter  is  secreted  at  all,  are  passed  invol- 
untarily. Eecovery  even  from  this  formidable  condition  is 
not  at  all  unusual  under  proper  management,  and  patients 
may  continue  to  live  on  for  years  without  the  recurrence 
of  ursemic  poisoning  in  an  acute  form. 

Chronic  urcemia  is  distinguished  from  the  acute  form  by  the 
fact  that  the  convulsive  attacks  rarely  assume  the  character 
of  violent  epileptiform  seizures,  nor  does  the  patient  pass  at 
once  into  a  state  of  deep  coma.  When  once  established  the 
symptoms  of  chronic  ursemic  intoxication  may  continue  for 
many  days  or  weeks,  or  may  never  be  completely  absent  till 
the  patient  dies.  The  chief  symptoms  are  twitching  of  cer- 
tain groups  of  muscles.  Headache,  chiefly  occipital  and 
often  of  a  neuralgic  character.  Intolerable  itching  of  the 
skin.  Vomiting,  especially  of  a  morning,  on  rising  before 
food  is  taken,  the  vomit  being  frequently  of  low  specific 
gravity  and  of  alkaline  reaction,  accompanied  with  trouble- 
some hiccup.  Asthmatic  paroxysms,  chiefly  occurring  at 
night,  and  accompanied  with  extremely  rapid  pulse,  and 
often  with  anginal  pains  over  the  region  of  the  heart  and 
in  the  epigastrium.  The  sleep  is  greatly  disturbed,  often 
preceded  by  distressing  jactitation,  whilst  the  rest  is 
broken  by  dreams  during  which  the  patient  grinds  his  teeth 
and  often  gives  utterance  to  moans  and  cries  of  anguish. 
Local  motor  and  sensory  paralyses  also  are  frequently 
complained  of.     The  vision  is  also  more  or  less  impaired, 


GENERAL    SYMPTOMATOLOGY. 


25 


and  the  ophthalmoscope  generally  reveals  haBmorrhage 
into  the  retina  and  other  changes  {vide  fig.  3,  p.  35),  though 
ursemic  amaurosis  does  occur  without  these  heen  present. 
The  connection  subsisting  between  these  nervous  symp- 
toms and  diffuse  inflammation  of  the  kidney  was  early 
admitted,  though  considerable  difference  of  opinion  has 
been  since  expressed  with  regard  to  their  causation.  The 
views  that  have  been  brought  forward  may  be  conveniently 
considered  as  expressing  the  chemical  theory  and  the  me- 
chanical theory  respectively. 

The  chemical  theory  was  originally  suggested  by 
Christison  and  was  based  on  the  supposition  that  a 
considerable  accumulation  of  urea  occurred  in  the 
blood.  Subsequent  experiments  have  shown  that  con- 
siderable quantities  of  urea  injected  into  the  vessels  of 
animals  do  not  induce  convulsions  of  a  ursemic  character, 
unless  the  animals  are  nephrotomised,  besides  which 
chnical  experience  teaches  us  that  large  accumulations  of 
urea  may  occur  in  the  blood  without  the  occurrence  of 
uremia.  These  facts  struck  Frerichs  at  an  early  stage  of 
the  controversy,  and  he  brought  forward  the  view  that 
though  urea  itself  might  be  innocuous,  or  fail  to  induce 
convulsions  of  a  urgemic  character,  yet  if  converted  into 
ammonium  carbonate  in  the  system  its  poisonous  action 
at  once  declared  itself.  He  based  this  theory  of  "am- 
monasmia "  on  the  following  arguments,  viz.,  that  in 
the  breath  of  patients  suffering  from  kidney  disease 
ammonia  can  be  demonstrated,  and  that  ammonia  is 
also  found  in  the  contents  of  the  stomach,  the  bile  and 
other  secretions  ;  and  that  injections  of  ammonia  into  the 
veins  of  animals  induce  convulsions  and  stupor.  To  this 
it  has  been  objected,  that  the  presence  of  ammonia  in  the 
breath  and  secretions  is  no  evidence  of  the  decomposition 
of  urea  in  the  blood,  but  simply  that  the  urea  is  transuded 


26  DISEASES    OF    THE    KIDNEY. 

to  the  mucous  surfaces  where  it  undergoes  conversion  into 
ammonium  carbonate.  In  chronic  Bright' s  disease  there 
is  no  doubt  that  urea  is  found  on  the  mucous  surfaces ; 
even  in  health  it  is  even  supposed  to  be  present,  since 
the  most  rational  explanation  of  the  formation  of  po- 
tassium sulpho-cyanate  in  saliva,  is  that  which  attri- 
butes it  to  the  decomposition  of  urea  in  the  mouth  and 
and  the  union  of  the  cyanogen  with  potassium  sulphate. 
Moreover,  analyses  have  failed  hitherto  in  giving  satisfac- 
tory proof  of  the  presence  of  ammonium  carbonate  in  the 
blood  of  animals  poisoned  with  urea,  or  nephrotomised,  or  in 
the  blood  of  persons  dying  from  acute  or  chronic  Bright's 
disease.  Some  observers  have  attributed  the  symptoms 
to  other  chemical  substances,  either  present  in  excess,  or 
of  abnormal  character.  Thus  D'E spine  has  found  an  in- 
crease of  potash  salts  in  the  blood  of  scarlet  fever  uraemia, 
and  has  suggested  that  the  symptoms  are  due  to  the  well 
known  poisonous  action  of  potassium  in  excess..  This 
view  was  originally  suggested  by  Voit,  who  thought 
the  potassium  salt  was  yielded  by  a  retrograde  meta- 
morphosis of  muscular  tissue  in  Bright's  disease..  Schiffer 
and  Brieger  have  brought  forward  the  view  that  ursemic 
convulsions  are  the  result  of  the  formation  in  the  blood  of 
alkaline  ptomaines.  These  suggestions,  though  plausible  in 
themselves,  are  not  supported  with  sufficient  evidence  to 
allow  as  yet  of  positive  criticism,  though  they  suggest  a 
field  for  valuable  research. 

The  mechanical  theory  was  originally  proposed  by 
Traube  it  is  based  on  the  following  propositions  ;  (a)  that 
in  chronic  Bright's  disease  there  always  exists  a  diluted 
state  of  the  blood  serum  ;  (b)  that  uremic  convulsions  are 
almost  invariably  associated  with  that  form  of  kidney  dis- 
ease characterized  by  hypertrophy  of  the  left  heart  and 
tension  of  the  aortic  system ;   (c)  that  in  all  cases  in  which 


GENBBAL    SYMPTOMATOLOGY.  27 

the  brain  had  been  examined  after  death,  he  had  been 
able  to  confirm  tlie  existence  of  a  more  or  less  considerable 
oedema  of  that  organ  together  with  marked  bloodlessness 
From  these  considerations  he  assumes  that  the  pheno- 
mena of  an  nrsemic  attack  depend  on  an  oedematous 
effusion  of  the  brain  brought  about  by  increased  pressure 
acting  on  diluted  and  watery  blood  serum.  The  objec- 
tions urged  against  this  view  may  be  thus  summarized : — 
(a)  Ursemic  convulsions  though  these  do  not  occur  in 
chronic  nephritis  till  cardio- vascular  changes  appear,  often 
accompany  acute  nephritis,  a  condition  then  closely  resem- 
bling that  of  a  nephrotomised  animal ;  viz.,  a  general  poi- 
soning of  the  body  with  excretory  materials.  (6)  That  the 
chronic  nephritis  associated  with  high  arterial  tension, 
is  attended  with  a  profuse  secretion  of  urine,  and  the 
blood  in  this  condition  is  not  hydrsemic,  and  also  that 
while  the  high  tension  is  maintained,  oedema  is  not  ob- 
served in  this  form  of  chronic  nephritis.  (c)  That  the 
form  of  chronic  nephritis  which  is  generally  associated 
with  oedema  is  usually  unattended  with  ursemic  attacks. 
In  addition  to  these  considerations,  Cohnheim  and 
others  have  objected  to  Traube's  view  on  experimental 
grounds. 

The  view  that  I  am  disposed  to  take  of  this  disputed 
question  is  that  considering  the  complex  nature  of  the 
symptoms  we  term  uremic,  we  must  not  look  for  an 
explanation  of  them  merely  as  regards  the  retention 
of  a  poisonous  agent  in  the  blood,  or  to  a  localized 
oedema  of  the  brain,  but  to  a  general  condition  of  the 
whole  system.  If  we  nephrotomise  an  animal,  for  example, 
there  is  not  merely  an  accumulation  of  the  urinary  con- 
stituents in  the  blood,  but  there  is  also  a  general  accumu- 
lation of  the  excretory  products  in  the  tissues  of  the  body. 
Thus  Hoppe  Seyler  examined  both  the  blood  and  tissues 


28  DISEASES    OF    THE    KIDNEY. 

of  a  patient  who  died  of  acute  ursemia,  and  found  that 
whilst  the  blood  contained  1-27  parts  of  urea  per  1000, 
the  muscles  contained  1*59  parts  of  kreatin.  Oppler 
(Virch.  Archiv,  Bd.  21,  s.  260)  also  found  a  large  quantity 
of  kreatin,  as  well  as  leucin,  in  the  muscles  of  nephroto- 
mised  animals,  and  argues  from  this,  as  weU  as  from 
Hoppe  Seyler's  cases,  that  the  result  of  the  stoppage  of  the 
kidney  functions  is,  for  enormous  quantities  of  decomposi- 
tion products  to  arise  and  accumulate  in  the  muscles,  and 
he  considers  himself  justified  in  coming  to  a  conclusion 
that  the  nervous  centres  are  similarly  affected,  and  that 
alterations  of  chemical  composition  are  brought  about  in 
them.  Schottin  has  shown  that  the  relation  of  the  ex-  . 
tractive  substances  to  the  albumin  of  the  blood  serum  are  '^ 
very  considerably  changed  in  chronic  renal  disease,  for 
whereas  in  health  they  are  as  5  to  100  respectively,  in  a 
case  of  degenerated  kidneys  he  found  them  as  40  to  100. 
Another  point  to  which  attention  may  be  drawn  is  the  fact 
that  in  uraemia  attended  with  suppression  of  urine,  a  con- 
siderable amount  of  acid  is  retained  in  the  system  (equal 
certainly  to  two  grammes  of  oxalic  acid  daily),  and  even 
in  chronic  Bright' s  disease  diminished  alkalinity  takes 
place,  for  Garrod  has  pointed  out  that,  as  in  gout  and  in 
collapsed  cholera,  the  blood  in  chronic  albuminuria  often 
approaches  the  neutral  point.  Now  when  we  reflect  on  the 
grave  constitutional  disturbances  that  follow  on  attempts 
to  reduce  the  alkaUnity  of  the  blood  in  animals,  and  the 
diminished  power  of  oxidation  that  follows  on  such  reduc- 
tion we  can  see  how  this  condition  reacts  on  the  tissues 
already  overcharged  with  the  products  of  arrested  meta- 
boUsm.  Especially  is  this  the  case  with  the  nervous 
system  which  resents  more  rapidly  and  distinctly  than  any 
other  organ  disturbances  of  its  nutrition. 
(2)  Acetoncemia : — Closely  aUied  to  uraemia  is  the  comatose 


GENERAL    SYMPTOMATOLOGY.  29 

condition  which  so  often  terminates  cases  of  diabetes, 
more  especially  those  occurring  in  young  subjects  and 
of  an  acute  character.  Since  acetone,  or  an  acetone 
yielding  substance,  is  frequently  found  in  the  urine  of 
these  cases,  the  coma  is  supposed  to  be  due  to  poisoning 
of  the  blood  by  this  substance.  Considerable  doubt, 
however,  exists  as  to  the  real  nature  of  this  coma  and 
the  agency  by  which  it  is  brought  about.  Free  ace- 
tone has  not  as  yet  been  discovered  in  the  blood,  though 
there  is  little  doubt  that  this  body  can  be  obtained  from 
the  urine.  Indeed  recent  researches  show  that  the 
peculiar  mahogany-red  coloration  with  ferric  chloride,  and 
the  iodoform  reaction,  sometimes  developes  in  urine  appa- 
rently healthy,  as  if  acetone,  or  acetone  yielding  substances, 
might  be  present  in  small  quantities  under  normal  con- 
ditions. It  has  also  been  shown  to  exist  in  very  appreci- 
able amounts  in  other  morbid  conditions  besides  diabetes, 
(Windle,  Liverpool  Medico- Chirurgical  Journal,  Jan,  1884), 
(Eiess,  Zeit.  f.  Klin.  Med.,  Bd.  vii.  Suppl.  1883),  and 
this  is  especially  noticeable  in  cases  of  anaemia.  The  in- 
troduction, experimentally,  of  large  quantities  of  acetone, 
or  of  acetone  yielding  substances,  such  as  ethyl  diacetate, 
and  aceto- acetic  acid,  into  the  bodies  of  animals  seems 
to  be  followed  by  no  ill  effects  (Frerichs,  Zeit.f.  Klin.  Med., 
Bd.  vi.  1883),  and  large  quantities  10  to  15  grammes, 
may  be  taken  before  the  urine  gives  the  peculiar  re- 
action of  acetone.  The  question  therefore  arises  whether 
diabetic  coma  is  due  to  its  sudden  and  excessive  formation 
and  accumulation  in  the  blood,  or  whether  we  must  re- 
gard diabetic  coma  as  due  to  other  causes.  In  the  first 
place  it  is  important  to  distinguish  especially  the  form  of 
coma,  and  limit  it  to  one  characterized  by  certain  special 
features.  Probably  all  cases  of  diabetes  die  more  or 
less  in  a  comatose  state,  but  the  acute   diabetic  coma  has 


80  DISEASES    OF    THE    KIDNEY. 

certain  distinguislimg  symptoms  which  cannot  fail  to 
attract  attention.  In  the  first  x^lace  its  onset  is  sudden 
commencing  with  sharp  epigastric  pain  and  gastric  distur- 
bance, sometimes  actual  vomiting,  which  vomit  has  been 
observed  in  some  cases  to  contain  blood  ;  in  a  few  cases 
purging  has  been  noticed.  Almost  coincidently  the  patient 
is  seized  with  dyspnoea  of  a  pecuhar  panting  irregular 
character,  "  ah'  hunger  ;  "  then  sets  in  a  condition  of  rest- 
lessness which  often  passes  into  delmum  of  noisy  character. 
Almost  suddenly  the  restlessness  and  delh-ium  cease  and 
the  patient  falls  into  deep  coma.  The  temperature  at  the 
onset  is  usually  below  the  normal ;  the  pulse  irregular  at 
first,  becomes  on  the  supervention  of  coma  extremely  weak, 
rapid  and  thready.  The  odours  of  acetone  may  be  pre- 
sent throughout,  but  usually  diminishes  markedly  from 
the  onset  of  the  attack.  Many  of  the  symptoms  above 
enumerated  have  a  close  parallelism  with  those  that  are 
attendant  on  death  in  acute  yellow  atrophy,  phosphorus 
poisoning,  or  poisoning  by  the  injection  of  acids  experi- 
mentally into  the  blood,  whilst  the  post-mortem  changes 
bear  out  this  parellelism  to  a  further  extent,  since  in  some 
of  the  cases  of  acute  diabetes  recorded,  fatty  degeneration 
more  or  less  intense,  together  with  a  lactescent  condition 
of  the  blood  seem  alhed  to  the  acute  fatty  changes  pro- 
duced by  phosphorus  poisoning,  or  poisoning  by  oxahc  acid, 
sulphuric  acid,  bile  acids,  etc.  These  considerations  cer- 
tainly seem  to  warrant  us  in  regarding  the  acute  forms  of 
diabetic  coma  as  due  to  a  toxic  agent ;  and  that  this 
agent  to  be  of  an  acid  nature,  probably,  derived  from  al- 
coholic fermentation  of  the  glucose  in  the  blood.  Nor  does 
the  fact  that  acetone  is  found  in  the  urine  when  no  sugar 
is  present,  invahdate  this  view,  since  it  is  probable  that 
small  quantities  of  acetone  or  of  acetone  yielding  products 
are  constantly  bsing  formed  in  the  stomach  during  the 


GENEEAIi    SYMPTOMATOLOGY.  31 

process  of  vinous  fermentation  of  the  saccharine  and 
amylaceous  constituents  of  the  food,  and  absorbed  into  the 
blood,  indeed  in  some  forms  of  dyspepsia  especially  in 
those  caused  by  alcoholism,  the  odour  of  acetone  can 
oftentimes  be  detected  in  the  breath.  Under  ordinary 
circumstances,  however,  the  acetone  thus  absorbed  is 
speedily  destroyed  in  the  blood ;  but  occasionally  and  es- 
pecially in  conditions  of  anemia  when  oxidation  is  but 
feebly  conducted,  the  substance^is  not  completely  destroyed 
and  some  portion  of  it  appears  in  the  urine.  In  diabetes 
the  acetone  yielding  substance  is  probably  present  in  the 
blood  to  some  extent  in  all  cases,  and  if  as  is  now  most 
generally  held,  this  substance  is  aceto-acetic  acid  it  accounts 
for  the  highly  acid  reaction  of  the  urine  so  characteristic 
of  the  disease.  When  the  quantity  formed  is  not  excessive 
and  the  kidneys  maintain  their  functional  activity  the 
substance  is  ehminated  without  causing  any  disturbance  in 
the  body,  since  we  know  by  experiments  on  animals,  that 
considerable  quantities  can  be  ingested  without  evil  results ; 
but  when  excessive  quantities  are  formed,  or  what  per- 
haps is  more  likely,  when  the  kidney  functions  fail,  an 
excessive  quantity  is  suddenly  accumulated  in  the  blood 
then  toxic  symptoms  immediately  manifest  themselves. 
This  failure  of  kidney  function  may  be  brought  about 
simply  by  exhaustion  consequent  on  long  continued  over 
activity  of  function  from  the  secretion  of  a  urine  loaded 
with  abnormal  material  (glucose),  besides  containing  ex- 
cess of  urea  and  water. 

When  the  poisoning  is  acute,  and  the  amount  of  the 
toxic  element  very  great,  then  on  post-mortem  examina- 
tion we  find  the  maximum  of  fatty  changes,  the  lactescent 
condition  of  the  blood,  the  fat  emboli  and  the  acute  fatty 
changes  in  the  hepatic  cells  and  in  the  muscular  fibres. 
When  the  process  is  less  acute,  then  we  meet  with  fatty 


32  DISEASES    OF    THE    KIDNEY. 

clianges  of  a  less  pronounced  character,  and  whicli  may 
escape   recognition   unless   diligently  looked   for.      Wifcli 
regard  to  the  nature  of  the  acetone  yielding  substance  as 
it  exists  in  the  blood,  a  difference  of  opinion  still  exists,  it 
is  probable,  however,  that  it  is  aceto-acetic  acid  and  not 
ethyl  diacetate  as  first  supposed,  the  reasons,   chemical 
and   chnical,  for   this   assumption   I  have  already  given 
{Path.  Soc.  Trans.,  1883,  p.  331).      This  substance,  how- 
ever, does  not  probably  exist  in  a  free  state  in  the  blood, 
but  is  probably   combined  with   an  alkaline  base,  most 
likely  soda.     As  aceto- acetate  of  soda  it  is  conveyed  to 
the  kidneys  and  other  mucous  surfaces,  in  the  capillaries 
of  which  it  probably  undergoes  decomposition  into  alcohol 
and  acetone,  though  as  far  as  the  urine  is  concerned  some 
portion  of  it  passes  through  as  acetic  acid,  since  many 
diabetic  urines  undoubtedly  contain  a  considerable  amount 
of  this  acid.     Minkowski  and  Kiilz  have  also  discovered  an 
.  acid,  resembhng  pseudo-oxybutyric  acid  in  diabetic  urines. 
In  addition  to  death  by  acute  coma,  a  fatal  termination 
sometimes  occurs  very  suddenly  without  any  evidence  of 
previous  intoxication,  rather  through  sudden  failure  of  the 
heart,  syncope,  than  by  coma.      This  condition  together 
with  others  relating  to  the  post-mortem  appearances  in 
the  bodies  of  persons  dying  of  diabetes  will  be  referred  to 
in  the  chapter  set  aside  for  the  consideration  of  that  disease. 
(3)  Neuralgia. — Severe  attacks  of  neuralgia  are  not  at 
all   uncommon  in  patients   suffering  from  chronic  renal 
disease,  especially  that  form  associated  with  cardio-vascu- 
lar  changes  and  is  another  evidence  of  how  profoundly  the 
nutrition  of  the  nervous  centres  is  affected.      A  common 
form  is  severe  racking  pain  in  the  occipito-cervical  region  ; 
whilst  visceral   neuroses   are    frequently   complained   of, 
the  chief  being  anginal  seizures,  occurring  generally  at 
night-time,   associated  with  attacks   of   dyspnoea   (renal 


GENERAL    SYMPTOMATOLOGY.  33 

asthma"),  and  racking  pains  commencing  in  the  epigastrium 
and  shooting  down  into  the  abdominal  and  pelvic  regions. 
In  diabetes  the  patient  often  suffers  from  similar  neuralgic- 
seizures,  the  most  common  of  which  are  those  especially 
affecting  the  stomach  and  liver.  These  pains  vary  in 
intensity  in  different  cases,  in  some  they  amount  to  no 
more  than  a  gnawing  feeling  like  the  cravings  of  hunger, 
but  in  others  the  attacks  are  excruciating,  "like  having  the 
liver  forcibly  compressed  and  twisted  out  of  you  "  as  a 
patient  once  expressed  it  to  me.  Diabetic  patients  also 
suffer  greatly  from  lumbar  and  sciatic  pains.  Of  the  lat- 
ter there  are  two  kinds,  one  following  the  course  of  the 
nerve  from  the  hip  to  the  ankle,  the  other  being  deeper, 
seated  apparently  in  the  bone,  generally  limited  to  the 
region  of  the  hip,  but  sometimes  extending  down  the  whole 
length  of  the  femur.  The  pain  has  been  spoken  of  as  if 
the  bone  was  being  crushed  or  bruised.  These  sciatic 
pains  have  been  alluded  to  by  some  recent  writers  as  if 
they  were  a  newly  discovered  clinical  feature,  but  although 
not  prominently  noticed  by  some  of  the  later  authors  who 
speak  of  them  as  radiating  lumbar  pains,  still  the  dis- 
tinction between  lumbar  pain  and  pain  in.  the  hips  and 
sciatic  region  was  early  made.  Thus  Paracelsus  enume- 
rates among  the  symptoms  of  diabetes,  "  dolor  spin^  quae 
plerumque  in  ischia  incipit."  These  sciatic  pains  have  been 
considered  to  be  of  a  rheumatic  character,  and  the  salicylates 
have  been  employed  with  benefit,  in  some  cases,  for  their 
relief.  But  admitting  the  value  of  the  salicylates  in  some 
forms  of  glycosuria  and  even  in  some  cases  of  established 
diabetes,  and  also  the  benefit  derived  by  their  use  in  the 
sciatica  sometimes  accompanying  these  forms,  yet  I  am 
not  disposed  to  believe  that  this  painful  complication  is 
dependent  on  rheumatism.  Indeed  the  fact  that  the  pain 
comes  on  most  severely  shortly  after  food  and  decreases  in 


34  DISEASES    OF    THE    KIDNEY. 

severity  as  the  influence  of  the  meal  passes  off,  points 
rather  to  an  increase  of  the  saccharine  matter  in  the  blood. 

6.  Ophthalmoscopic  changes. — The  special  changes 
which  may  be  observed  in  the  retina  and  its  vessels  in  the 
chronic  forms  of  Bright's  disease,  according  to  Gowers 
from  whose  work  on  Medical  Oj^hthahiioscojjy  the  following 
summary  has  been  taken,  are  as  follows  : — 

(1)  A  diffuse  slight  opacity  and  swelling  of  the  retina, 
due  to  oedema.  (2)  White  spots  or  patches  of  various 
size,  for  the  most  part  the  result  of  degeneration  processes. 
(3)  Hemorrhages.  (4)  Inflammation  of  the  intra-ocular 
end  of  the  optic  nerve.  (5)  Atrophy  of  the  retina  and 
nerve  may  sometimes  result  from  and  succeed  the  inflam- 
matory changes.      These  changes  may  affect  one  eye  only. 

These  conditions  are  not,  however,  equally  promi- 
nent in  every  case,  but  vary  according  to  the  stage  and 
form  of  the  disease.  According  to  the  element  that  is 
most  conspicuous  four  types  may  be  distinguished.  In 
the  degenerative  form,  which  is  most  common,  small  whit- 
ish spots  rounded  at  first,  but  becoming  irregular  as 
they  increase,  form  in  the  retina.  These  may  be  ob- 
served near  the  optic  nerve  entrance,  or  at  a  distance 
often  very  small  white  spots  are  arranged  in  a  radiating 
manner  round  the  macula  lutea.  Sometimes  larger  spots 
Coalesce  to  form  white  areas,  which  surround  the  disc. 
These  changes  may  occur  without  any  alteration  of  the 
disc  itself,  but  sometimes  its  edge  becomes  blurred,  and 
the  tint  reddish-grey.  Hasmorrhages  are  of  less  frequent 
occurrence  than  in  the  other  forms,  when  they  occur  they 
are  usually  adjacent  to  the  white  spots.  When  small 
they  have  a  striated  arrangement,  the  blood  lying  be- 
tween the  nerve-fibres  ;  they  are  often  parallel  to  vessels. 
When  larger  they  are  often  flame- shaped  or  irregular. 
Irregular  and  rounded  hsemorrhages  are  in  the  deeper 
layers  of  the   retina.      In   the   inflammatory  form  there 


GENERAL  SYMPTOMATOLOGY.  35 

is  general  swelling  of  the  retina  with  obscuration  of 
the  disc.  The  arteries  are  concealed,  whilst  the  veins  if 
visible  are  tortuous  and  distended.  HaBmorrhages  are 
numerous,  large  and  striated.      White  spots,  more  or  less 


Fig.  3. — Albuminuric  fietinitis. 

uniform  in  character,  especially  in  acute  cases,  are  abun- 
dant, large,  rounded,  and  soft  edged.  In  the  neuritic  form, 
the  edges  of  the  optic  disc  are  veiled  by  a  greyish-red 
swelHng  of  moderate  degree.  The  arteries  are  narrow 
and  the  veins  curve  over  the  side  of  the  swelling.  On 
oblique  illumination,  a  white  reflection  may  frequently 
be  observed  at  certain  spots  on  the  surface  of  the  swell- 
ing. SUght  degenerative  changes  usually  accompany  this 
form,  and  careful  examination  will  detect  one  or  more 
white  spots  near  the  neuritic  swelling.     Haemorrhages  are 

1)2 


36  DISEASES    OF    THE    KIDNEY. 

of  rare  occurrence.  This  form  when  it  suhsides,  may  be 
followed  by  atrophy.  The  hamorrhagic  form  is  charac- 
terised by  the  size,  number,  and  predominance  of  the 
hEemorrhages,  accompanied  with  but  shght  degenerative 
change  or  inflammation  of  the  disc  or  retina.  In  the 
earher  stages  vifion  is  usually  iinaffected,  but  as  the 
changes  progress,  it  becomes  more  dull  (amblyopia), 
though  sight  is  rarely  altogether  lost,  colour  vision  may, 
in  rare  cases,-  be  affected. 

With  regard  to  the  causes  producing  the  degenera- 
tive, inflammatory,  and  neuritic  forms,  only  hypothe- 
tical suggestions  have  been  advanced.  The  haemor- 
rhage, no  doubt,  results  from  rupture  of  degenerated 
vessels,  under  the  stress  of  increased  pressure  from  an 
hypertrophied  left  ventricle.  In  addition  to  these  well 
marked  alterations,  the  arteries  of  the  retina,  especially 
in  granular  kidney,  undergo  diminution  from  one- half  to 
one-third  of  their  volume,  and  when  shght  swelling  of 
the  retina  co- exists,  the  arteries  may  be  invisible  beyond 
the  papilla.  In  these  cases  as  Dr.  Gowers  has  pointed 
out,  the  pulse  is  characteristically  incompressible.  The 
frequency  of  observation  of  these  retinal  changes,  depends 
much  on  the  stage  of  the  disease,  when  it  first  comes  under 
notice,  and  its  character.  Thus  they  are  most  commonly 
met  with  in  the  granular  kidney,  and  rare  in  lardaceous 
disease,  whilst  in  all  forms  the  disease  must  have  been  in 
progress  some  time  before  they  occur.  Dr.  Gowers  agrees 
with  the  statistics  collected  by  Eales  who  in  one  hundred 
cases  of  chronic  disease,  found  retinal  changes  in  twenty- 
eight  per  cent,  or  one  in  every  three  and  a  half  cases. 
Besides  these  characteristic  changes,  other  conditions  may 
from  time  to  time  be  noted,  as  haemorrhage  and  degen- 
ration  of  the  choroid,  detachment  of  the  retina  from 
serous  effusion  between  it  and  the  choroid ;  haemorrhage 


GENEBAL    SYMPTOMATOLOGY.  37 

into  the  vitreous  ;    and  aneurismal  dilation  of  the  small 
vessels  of  the  retina. 

Temporary  amaurosis  may  occur  during  the  progress  of 
chronic  Bright's  disease,  without  there  being  any  ophthal- 
moscopic indication  whatever  to  account  for  it,  it  is  prob- 
ably only  a  manifestation  of  the  state  of  general  ursemic 
intoxication,  which  accompanies  granular  degeneration  of 
the  kidneys. 

In  saccharine  diabetes  the  patient  is  liable  to  impair- 
ment or  loss  of  sight;  the  conditions  producing  this  are  : — 
(1)  Cataract.  (2)  Impaired  condition  of  the  blood.  (3) 
Changes  in  the  fundus  oculi. 

Diabetic  cataract  is  usually  large  and  soft,  and  occurs  in 
an  advanced  stage  of  the  disease.  That  sugar  has  a 
direct  action  in  producing  this  opacity  of  the  lens,  seems 
to  be  proved  by  the  fact  that  frogs  placed  in  sweetened 
water,  speedily  become  cataractous.  Amblyopia,  with  the 
absence  of  ophthalmoscopic  appearances,  is  not  of  infre- 
quent occurrence  ;  it  is  attributed  to  the  circulation  of 
some  toxic  element  in  the  blood,  but  of  what  nature  is  not 
determined.  It  can  hardly  be  the  amount  of  sugar,  since 
no  proportion  seems  to  exist  between  the  excretion  of 
sugar  and  the  degree  of  amblyopia.  Although  frequent  in 
confirmed  and  severe  cases,  it  is  as  far  as  my  experience 
goes,  quite  as  often  complained  of  in  mild  cases.  It  may 
be  interesting  in  future  enquiries  to  ascertain  if  this  symp- 
tom bears  any  relation  to  the  amount  of  acetone  found 
in  the  urine.  The  changes  observed  in  the  fundus  oculi, 
may  be  thus  enumerated.  Simple  atrophy  of  the  optic 
nerve  has  been  observed  in  some  cases.  In  a  few  there 
has  been  a  central  defect  in  the  field  of  vision,  for  colour 
or  white,  as  in  tobacco  amblyopia,  and  this  when  the 
influence  of  tobacco  could  be  excluded.      Earely  retinal 


38  DISEASES    OF    THE    KIDNEY. 

changes  are  observed,  these  Dr.  Gowers  describes  as  bear- 
ing a  resemblance  to  those  of  albuminuria,  and  still  more 
so  to  those  of  pernicious  anaemia.  The  retinal  changes, 
when  present,  are  hfemorrhages  chiefly  found  in  the  nerve 
fibre  layers,  these  may  lead  to  secondary  retinitis,  or  by 
their  infiltration  into  the  vitreous  may  cause  opacities  in 
it,  or  even  hfemorrhagic  glaucoma.  White  spots  of  de- 
generation are  also  frequently  found  scattered  over  the 
fundus  of  the  eye,  and  atrophy  of  the  optic  nerve  has  been 
observed.  The  presence  of  considerable  optic  neuritis 
in  cases  of  diabetes,  mellitus  and  insipidus,  vs^ould  lead 
one  to  suspect  the  existence  of  organic  braiij  disease. 

6.  Derangements  of  the  Respiratory  System.  - 
Pulmonary  complications  form  the  most  frequent  termina- 
tion of  chronic  renal  disease.  Renal  asthma  occurs  in  its 
most  marked  form  in  patients  suffering  from  primary  con- 
tracted kidney,  and  apparently  depends  upon  a  uraemic 
condition  of  the  blood,  since  in  many  cases  vs^e  are  unable 
to  attribute  it  to  any  other  cause  except  nervous  spasm. 
In  some  cases  the  frequency  and  intensity  of  ihe  attacks, 
apparently  correspond  to  an  mcreased  tension  of  the  radial 
pulse,  with  a  strong  heaving,  but  somewhat  irregular,  ac- 
tion of  the  heart.  But  severe  paroxysms  may  occur  quite 
independently  of  any  changes  in  the  pulmonary  or  circu- 
latory systems,  and  indeed  in  persons  in  every  respect 
apparently  healthy.  In  two  patients,  one  a  country  gen- 
tleman, who  were  able  to  take  strong  and  even  fast  exercise 
without  distress  to  their  breathing,  attacks  of  renal  asthma 
first  called  attention  to  the  condition  of  their  kidneys. 
Both  had  thought  themselves  strong  hearty  men,  and 
attributed  the  seizures  to  attacks  of  indigestion.  The 
paroxysms  of  renal  asthma  almost  invariably  occur  in  the 
night  time,  and  during  the  earlier  hours  of  the  night. 
When  they  come  on  in  the  day  time  it  is  generally  in  con- 


GENERAL    SYMPTOMATOLOGY.  39 

sequence  of  some  nervous  agitation,  or  as  a  prelude  to 
more  severe  urasmic  manifestations.  The  paroxysms,  how- 
ever, never  attain  the  severe  grade,  nor  come  on  so  sud- 
denly as  in  pure  nervous  asthma,  or  as  in  the  dyspnoea 
associated  with  acetonaemia.  The  course  is  usually  as  fol- 
lows, soon  after  the  patient  has  gone  to  bed  he  experi- 
ences a  sense  of  oppression  at  the  chest,  often  accompanied 
with  pains,  which  radiate  from  the  cardiac  regions, 
into  the  epigastric  and  hypochondriac  regions.  Soon 
this  feeling  of  weight  and  oppression  is  succeeded  by  in- 
creased difficulty  of  breathing,  and  inspiration  becomes 
short  and  laboured,  whilst  rhonchus  is  heard  over  the 
whole  chest.  The  lips  and  face,  however,  rarely  become 
livid,  and  the  paroxysm  after  lasting  about  two  hours, 
gradually  subsides.  The  attacks  are  often  followed  by  an 
increased  flow  of  pale  urine  of  low  specific  gravity  ;  even 
in  cases  were  it  is  already  abundant,  the  increase  is  suffi- 
cient to  attract  the  patient's  attention.  The  paroxysms 
come  on  usually  for  several  nights  in  succession,  and  then 
may  leave  the  patient  free,  perhaps  for  a  considerable  in- 
terval. Neither  their  going,  or  their  coming,  can  be 
accounted  for  by  any  alteration  in  the  general  condition  of 
the  patient.  They  will  attack  the  same  individual  on  one 
occasion  when  he  seems  to  be  in  fair  average  health,  and 
fail  to  recur  when  he  falls  back,  and  vice  versa.  Equally 
associated  with  a  toxic  condition  of  the  blood  is  the  pecu- 
liar panting  dyspnoea  that  preceeds  or  accompanies  acute 
diabetic  coma,  and  which  is  supposed  to  be  due  to  the 
presence  of  an  acetone  yielding  substance  in  the  blood. 
This  dyspnoea  has  been  likened  to  panting,  caused  in  an 
animal,  whose  vagi  have  been  cut,  and  has  been  well  des- 
cribed as  "air  hunger,"  as  characterising  the  nature  of 
the  dyspnoea,  which  is  caused  not  by  the  difficulty  of  ob- 
taining air  by  obstruction  of  the  air-passages,  or  by  spasm 


40  DISEASES    OF    THE    KIDNEY. 

as  in  the  case  of  renal  asthma,  but  by  an  increased  demand 
for  air.  This  form  of  dyspnoea  sometimes  preceeds  dia- 
betic coma  by  some  hours,  and  may  be  the  sole  pre- 
monitory symptom.  Thus,  in  a  case  Dr.  J.  Duncan  asked 
me  to  see  with  him,  a  patient  who  for  some  weeks  had 
been  only  slightly  ailing,  but  whose  urine  contained  traces 
of  sugar,  was  seized  early  one  morning  with  dyspnoea, 
which  continued  about  six  hours,  when  coma  suddenly  set 
in  which  speedily  proved  fatal.  In  this  case  the  dyspnoea 
was  the  only  indication  for  some  hours,  that  the  disease 
which  was  apparently  a  mild  form  of  diabetes,  was  assuming 
a  rapidly  fatal  character.  Bronchitis,  pneumonia,  pleuritic 
effusions  and  cedetna  of  the  lungs  occur  as  complications  in 
both  forms  of  chronic  Bright's  disease,  though  clinically, 
with  the  exception  of  pneumonia,  they  are  essentially  asso- 
ciated with  the  pale  granular  form.  When  met  with 
in  the  interstitial  form  it  is  towards  the  end  of  the  dis- 
ease, when  owing  to  the  failure  of  the  hypertrophied  heart 
and  vessels,  the  secretion  of  urine  is  diminished,  and  a  ten- 
dency to  dropsy  is  established,  whilst  morbid  elements  accu- 
mulate in  the  blood.  The  bronchitis  of  the  pale  granu- 
lar kidney  is  always  more  or  less  associated  with  oedema  of 
the  lungs.  The  pneumonia  of  this  form  of  Bright's  disease  is 
of  the  ordinary  croupous  form,  whilst  when  it  occurs  in  the 
interstitial  form,  it  generally  assumes  the  character  of 
"  pulmonary  apoplexy  "  and  is  usually  attended  with  profuse 
haemoptysis.  Effusions  into  the  pleura,  pericardium  and 
peritonaeum  are  nearly  always  associated  with  the  pale 
granular  kidney,  when  they  occur  in  the  progress  of  the  other 
form,  it  is  towards  the  end,  and  even  then  they  are  never 
so  formidable  as  in  this  variety.  They  usually  come  on 
insidiously  and  rapidly,  and  the  amount  of  fluid  effused  is 
always  considerable.  They  are  rarely  attended  with  severe 
pain  or  fever.      In  many  cases  there  is  no  pain  at  all  and 


GENERAL    SYMPTOMATOLOGY.  41 

only  a  moderate  rise  of  temperature,  and  our  attention  may 
be  only  called  to  the  existence  of  this  complication  by  the 
increased  difficulty  of  breathing  and  decubitus  of  the 
patient.  Phthisis  though  frequently  associated  with 
chronic  Bright's  disease,  is  rarely  developed  during  its 
course,  and  is  nearly  always  an  antecedent  condition. 
Nephritis,  moreover,  when  it  occurs  in  a  phthisical  subject  is 
almost  invariably  preceded,  or  is  accompanied  by  waxy 
degeneration  of  the  kidney.  Phthisis,  however,  frequently 
occurs  in  diabetes  as  a  secondary  complication,  especially  in 
those  cases  that  run  a  chronic  course.  Indeed  in  referring 
to  the  older  writers,  we 'find  that  phthisis  is  mentioned  as  of 
such  frequent  occurrence,  as  to  be  considered  almost  "uni- 
versal." Though  this  universality  cannot  be  maintained 
in  the  present  day,  the  general  dependance  of  phthisis  in 
many  cases  of  diabetes  is  abundantly  proved.  At  the 
recent  debate  at  the  Pathological  Society,  [Transactions, 
1883),  Dr.  Stephen  Mackenzie  brought  forward  statistics 
from  the  London  Hospital  to  show  that  out  of  thirty- seven 
cases,  pneumonic  or  phthisical  mischief  was  x^resent  in 
twenty.  Dr.  Windle  [Dublin  Medical  Journal,  September 
1883),  has  recorded  the  result  of  833  post-mortems  on 
diabetic  subjects,  and  found  the  lungs  normal  in  seventy- 
five  instances  only ;  in  the  remaining  258  cases,  phthisis 
was  present  in  109  cases,  whilst  the  other  cases  showed 
recent  pneumonia,  congestion,  broncho-pneumonia,  etc. 
Dr.  Douglas  Powell,  however,  at  the  same  debate  ques- 
tioned whether  phthisis  and  diabetes  had  anything  in 
common,  and  brought  forward  statistics  from  the  Brompton 
Hospital,  which  showed  that  out  of  136  cases,  in  which  the 
urine  of  phthisical  patients  was  examined,  in  not  one  case 
was  sugar  found.  Dr.  Powell's  statistics,  however,  only 
prove  that  diabetes  has  no  dependance  on  phthisis,  whilst 
Dr.  Mackenzie's  and  Dr.  Windle's  show  the  converse,  viz., 


42  DISEASES    OF    THE    KIDNEY. 

that  phthisis,  or  some  pneumonic  changes  likely  to  pro- 
duce that  disease,  do  not  infrequently  develope  in  diabetic 
subjects. 

7.  Derangements  of  Digestion. — Acute  renal  affec- 
tions are  almost  invariably  accompanied  with  more  or  less 
disturbance  of  the  digestive  organs.  In  acute  nephritis, 
especially  in  the  catarrhal  form,  in  which  the  kidney  is 
usually  much  swollen,  vomiting  is  often  a  prominent 
symptom ;  in  the  less  severe  varieties,  scarlet  fever 
nephritis  for  instance,  the  disturbance  is  usually  less 
marked,  though  there  is  always  loss  of  appetite,  if  not  a 
certain  degree  of  nausea.  Nausea,  with  or  without  vomit- 
ing, is  also  a  very  constant  symptom  when  there  is  irrita- 
tion in  the  neighbourhood  of  the  capsule  or  pelvis  of  the 
kidney.  Thus,  it  is  frequently  found  attendant  on  peri- 
nephritis, when  the  capsule  is  pressed  upon  from  without ; 
in  renal  abcess,  pyo- nephrosis,  hydro-nephrosis  and  in  a 
rapidly  growing  carcinoma,  which  distend  the  capsule  from 
within ;  and  in  renal  calculus,  when  the  irritation  is 
applied  to  the  pelvis  of  the  kidney.  In  all  the  above 
mentioned  instances,  including  the  vomiting  of  acute 
Bright's  disease,  the  act  is  purely  reflex,  and  is  thus  to  be 
distinguished  from  the  vomiting  that  occurs  in  the  chronic 
forms  of  nephritis,  and  which  is  clearly  due  to  a  toxic  con. 
dition  of  the  blood  (uraemia).  This  reflex  gastric  dis- 
turbance sometimes  affords  us  timely  notice  of  the  invasion. 
of  kidney  mischief.  Thus,  in  scarlet  fever  if  a  patient, 
who  has  previously  been  convalescing  favourably,  com- 
plains of  a  feeling  of  nausea,  the  urine  should  be  at  once 
examined.  But  the  most  serviceable  indication  is  in  the 
warning  it  often  gives  in  cases  of  obstruction  of  the  lower 
urinary  passages  of  the  implication  of  the  kidneys.  And 
particular  enquiries  ought  to  be  made  into  the  condition  of 
the  urinary  organs,  in  all  cases  of  chronic  "biliousness'' 
especially  in  elderly  persons. 


GENEEAIi    SYMPTOMATOLOGY.  43 

The  vomiting  that  occurs  in  the  chronic  forms  of  Bright's 
disease  is,  as  already  stated,  due  to  the  toxic  condition  of  the 
blood  and  system  generally  and  is  often  one  of  the  earliest 
symptoms  of  chronic  uremia.  The  following  characters 
may  help  us  to  distinguish  the  two  forms.  Keflex  vomit- 
ing is  usually  attended  with  marked  gastric  disturbance, 
and  though  it  may  come  on  when  the  stomach  is  empty,  food 
either  nauseates  or  is  at  once  ejected.  The  vomit  consists 
at  first  of  a  glairy  highly  acid  fluid,  often  containing  undi- 
gested food,  and  is  not  very  profuse  ;  when  long  continued 
it  becomes  yellowish  and  subsequently  green  from  the 
bile,  which  the  action  of  vomiting  provokes  to  flow  from 
the  gall-bladder  into  the  duodenum  and  thence  into  the 
stomach.  Ursemic  vomiting  on  the  other  hand,  at  first  is 
generally  confined  to  the  morning  hours,  usually  on  first 
rising  in  the  morning,  though  later  in  the  disease  it  may 
occur  at  any  time  of  the  day.  The  vomit  is  usually  very 
profuse,  of  low  specific  gravity,  and  at  first  of  slightly 
acid  reaction  though  in  the  later  stages  of  the  disease  it  is 
often  alkaline  and  sometimes  contains  urea.  The  gastric 
disturbance  is  very  variable,  many  patients  with  chronic 
Bright's  disease,  especially  with  pale  granular  kidneys, 
have  not  only  good  appetites  but  are  even  ravenous  at 
times,  and  digest  their  food  with  comfort.  In  others  there 
is  simply  loss  of  appetite,  especially  as  regards  meat,  but 
no  indigestion.  Dyspepsia  when  it  occurs  in  these  cases 
is  usually  the  result  of  fermentative  changes  taking  place 
in  the  stomach,  especially  with  regard  to  the  albuminous 
constituents  of  the  food,  with  the  formation  of  lactic  acid, 
butyric  acid  and  hydrogen  in  form  of  marsh  gas,  hence 
the  sour  rancid  odour  sometimes  perceived  in  the  breath 
and  in  the  vomit  of  these  patients.  With  granular  kidneys, 
however,  associated  with  cardio-vascular  changes,  there  is 
generally  considerable  loss  of  appetite,  and  the  ingestion  of 


44  DISEASES    OF    THE    KIDNEY. 

food  is  often  attended  with  severe  epigastric  pains,  appar- 
ently of  a  neuralgic  character.  Diarrhcea  is  also  a  very 
frequent  complication  of  chronic  kidney  disease,  especially 
when  there  is  dropsy.  In  the  early  stages  it  affords  rehef  to 
the  water  logged  body,  but  towards  the  end  it  is  apt 
to  become  intractable  and  adds  to  the  existing  debility.  It 
is  therefore  necessary  to  use  caution  in  the  employment  of 
purgatives  for  the  relief  of  dropsy  when  the  disease  is 
drawing  to  a  close.  Diarrhoea  sets  in  suddenly  when  a 
peri-nephritic  or  renal  abscess  bursts  into  the  intestines, 
the  nature  of  the  diarrhoea  will  be  explained  by  the  sub- 
sidence of  the  tumour  and  the  appearance  of  pus  in  the 
motions.  A  consti2Jatecl  condition  of  the  bowels  is  gene- 
rally observed  when  there  is  any  considerable  enlargement 
of  the  kidney,  owing  to  the  compression  of  the  large  in- 
testine which  crosses  both  kidneys  on  their  anterior  surface. 
This  constipation  which  is  often  overcome  with  difficulty, 
is  often,  especially  in  the  case  of  malignant  tumours, 
followed  by  severe  diarrhoea,  most  difficult  to  arrest,  if  the 
means  resorted  to  for  its  relief  have  been  too  active.  Con- 
stipation too  is  the  prevailing  condition  of  the  bowels  in 
diabetes,  the  motions  when  the  bowels  are  relieved  being 
hard,  dry  and  scybalous.  In  some  cases  it  alternates 
with  diarrhoea,  the  loose  motions  being  often  frothy  and 
yeasty  in  appearance.  The  tongue  presents  no  character- 
istic feature  in  renal  disease,  except  in  some  cases  of  dia- 
betes. In  acute  affections  it  is  usually  coated  as  in  pyrexia 
generally.  In  chronic  Bright's  disease  it  varies  according 
to  the  condition  of  the  digestive  organs  being  sometimes 
broad,  flabby,  coated  and  somewhat  oedematous,  whilst 
in  other  cases  it  is  glazed,  beefy  looking  and  cracked.  In 
diabetes  too,  the  appearance  of  the  tongue  varies,  but  in 
some  cases,  and  those  I  have  noticed  to  be  invariably 
severe,  the  whole  of  the  tongue  assumes  a  pecuhar  bright 


GENERAL     SYMPTOMATOLOGY.  45 

red  appearance,  suggesting  the  idea  that  the  blood  is  flow- 
ing through  the  organ  without  being  properly  deprived  of 
its  arterial  character,  and  which  Dr.  Pavy  believes  is  caused 
by  vaso-motor  paralysis  of  the  vessels  of  the  chylopoietic 
vascular  system  and  which  he  considers  to  be  very  similar 
to  the  hypersemic  condition  of  the  ear  which  is  brought 
about  by  the  division  of  the. sympathetic  in  the  neck. 

8.  Derangements  of  the  Cutaneous  System. — 
In  acute  inflammatory  affections  of  the  kidneys,  the  skin 
presents  the  usual  character  noticeable  in  pyrexial  affections 
generally.  In  acute  nephritis,  however,  a  remarkable 
ivory  whiteness  and  pallor  (anaemia)  is  observed  at  a  very 
early  period,  whilst  the  subcutaneous  areolar  tissue  may 
become  infiltrated  and  swollen  with  dropsical  exudation. 
In  chronic  nephritis  associated  with  long  standing  dropsy, 
the  skin  apparently  loses  its  function,  at  all  events  it  is  ex- 
tremely dif&cult  to  get  it  to  act,  and  in  this  state  the  use 
of  powerful  diaphoretics  admmistered  with  the  view  of 
inducing  perspiration  is  often  followed  by  severe  headache, 
and  sometimes  by  more  alarming  cerebral  symptoms  (see 
Chapter  iii.,  §  Treatment).  In  the  granular  kidney  unat- 
tended with  dropsy,  the  skin  becomes  harsh  and  dry, 
having  sometimes  a  powdery  or  even  "frosted"  appear- 
ance ;  this  powdery  matter  is  said  to  consist  of  urea,  ex- 
creted vicariously  by  the  skin.  This  statement,  however, 
is  not  altogether  correct.  The  powdery  matter  it  is  true 
contains  urea,  but  the  greater  part  of  it  is  made  up  of 
broken  down  cuticular  cells  ;  this  detritus  is  more  abun- 
dant and  evident  in  this  disease  than  perhaps  in  others, 
owing  to  the  extreme  harshness  and  dryness  of  the  skin 
which  renders  the  cells  more  brittle,  and  also  to  the 
wrinkled  condition  of  the  skin  which  allows  it  to  collect  in 
the  furrows.  Patients  suffering  from  waxy  degeneration 
of  the  kidney  have,  in  addition  to  the  pecuhar  pallor  of 


46  DISEASES    OF    THE    KIDNEY. 

chronic  kidney  disease,  a  muddy  complexion  especially 
noticeable  by  the  brownish  rings  round  the  eyehds,  which 
Dr.  Grainger  Stewart,  who  first  drew  attention  to  this  fact, 
thinks  due  to  the  deposition  of  pigment  in  the  tissue- 
element  of  the  skin.  All  patients  suffering  from  chronic 
renal  disease  are  liable  to  erysipelatous  and  phlegmanous 
inJlammations  of  the  skin.  A  fact  that  should  be  borne  in 
mind,  in  the  treatment  of  pleurisy  or  other  serous  effusions, 
since  a  small  blister  or  even  a  mustard  plaster  ^ill  some- 
times give  rise  to  the  most  formidable  sloughing,  whilst 
for  the  rehef  of  dropsy  only  the  finest  punctures  should  be 
made.  In  diabetes  the  skin  is  harsh  and  dry,  and  it  often 
exhibits  the  sanae  powdery  or  frosted  appearance  noticeable 
in  granular  kidney,  and  sugar  has  been  obtained  from  the 
deposit.  Although  this  harsh  condition  of  skin  is  gene- 
rally maintained  throughout  the  disease,  attacks  of  profuse 
sweating  will  sometimes  set  in  in  the  most  unaccountable 
manner  ;  frequently  this  sweating  is  unilateral.  In  some 
cases  the  skin  remains  moist  throughout. 

Patients  suffering  from  diabetes  are  very  frequently 
troubled  with  boils  and  carbuncles.  They  are  also  liable 
to  other  skin  diseases,  though  not  in  the  same  degree  of 
frequency,  among  them  may  be  mentioned  eczema, 
psoriasis  and  impetigo.  Mild  forms  of  diabetes,  or  rather 
glycosuria,  are  often  associated  with  eczema,  both  being 
probably  due  to  the  same  cause,  viz.,  a  gouty,  rheumatic 
or  strumous  taint.  The  irritation  of  the  sugar  moreover, 
causes,  unless  means  be  taken  to  prevent  it,  a  considerable 
degree  of  irritation  of  the  external  genitals  which  if  neg- 
lected gives  rise  to  an  eczematous  condition  most  difficult 
to  deal  with.  Diabetic  patients  are  also  sometimes  troubled 
with  patches  of  psoriasis,  whilst  on  the  other  hand  persons 
who  are  the  victims  of  extensive  and  inveterate  psoriasis,  are 
often  found  to  be  glycosuric  as  well.      Impetiginous  erup- 


GENERAL    SYMPTOMATOLOGY.  47 

tions  also  are  by  no  means  infrequent.  At  the  Seamen's 
Hospital,  1878,  I  saw  a  very  severe  form  of  this  eruption 
attack  a  patient  suffering  from  diabetes.  It  came  out 
abundantly  upon  his  legs  and  thighs,  the  pustules  which 
were  distinct  were,  however,  thickly  clustered  together  and 
resembled  very  closely  the  fully  developed  stage  of  concrete 
small-pox,  only  they  were  not  umbilicated.  After  remain- 
ing out  about  a  month  or  six  weeks  they  slowly  subsided 
and  shortly  after  the  patient  died  of  acute  diabetic  coma. 


48  DISEASES   OF    THE    KIDNEY. 


CHAPTEE  It. 

CLiNiCAti  Examination  of  the  Ueine. 

9,  Method  of  Procedure.— The  following  rules 
should  be  attended  to : — 

{1)  When  the  patient  first  comes  under  observation,  he 
should  be  directed  to  empty  his  bladder.  The  quantity  of 
urine  thus  furnished  should  be  measured,  the  specific 
gravity  and  reaction  taken,  the  tests  for  abnormal  pro- 
ducts, sugar,  albumin,  etc.,  applied,  and  the  deposit  if  any 
examined  by  the  microscope  and  by  chemical  reagents. 
This  procedure  gives  us  an  insight  into  the  nature  of  the 
morbid  conditions,  bat  in  order  to  judge  of  their  extent  and 
permanence,  it  is  necessary  to  extend  our  consideration 
to  the  qualities  exhibited  by  the  whole  of  the  urine  passed 
during  the  twenty-four  hours. 

(2)  After  the  preliminary  investigation  above  described, 
has  been  concluded,  the  patient  should  be  directed  to  col- 
lect his  urine  for  the  period  of  twenty-four  hours.  In 
order  to  insure  accuracy  the  following  particulars  should  be 
attended  to.  The  bladder  must  be  thoroughly  emptied 
at  a  stated  hour,  say  8  a.m.,  which  is  to  be  recorded  and 
that  sample  rejected.  The  next  sample,  however,  must  be 
kept  and  placed  in  a  convenient  receptacle,  (a  special  form 
of  urine  jar,  capable  of  holding  five  pints  or  three  htres, 
and  graduated,  sold  by- Messrs.  Griffin,  Garrick  Street, 
Covent  Garden,  is  most  serviceable  for  this  purpose). 
Every  succeeding  sample  must  be  placed  in  the  jar,  the 
last  being  passed  exactly  at  8  a.m.,  the  next  day.     The 


CLINICAL    EXAMINATION    OF    THE    URINE.  49 

mixed  urine  thus  collected,  represents  tlie  urine  of  twenty- 
foar  hours,  and  is  to  be  accurately  measured.  In  hospital 
practice,  or  with  inteUigent  patients  in  private,  much  use- 
ful information  is  gained,  if  before  placing  each  sample  in 
the  jar,  the  quantity,  the  specific  gravity,  and  reaction  is 
also  noted.  By  an  examination  of  the  twenty-four  hours 
urine  we  learn  the  amount  of  water  and  the  quantity  of 
solids  eHminated  by  the  kidneys  in  that  period,  the  pre- 
vaiHng  character  of  the  reaction,  and  then  by  submitting 
portions  of  it  to  volumetric  analysis,  we  learn  if  it  be  desired, 
what  variations  from  the  normal  occur  among  the  usual 
constituents,  and  also  the  absolute  amount  of  any  morbid 
product,  albumin,  sugar,  etc.,  that  may  be  present. 

(3)  Having  determined  qualitatively  the  nature  of  the 
changes  of  the  urine  in  disease  from  an  examination  of  an 
individual  sample,  and  quantitatively  from  a  consideration 
of  that  passed  in  the  twenty-four  hours,  we  have  still  one 
investigation  to  make,  to  render  our  clinical  enquiry  com- 
plete, and  that  is  to  determine  the  influence  of  food  and 
rest  on  the  character  of  the  secretion. 

For  this  purpose  it  is  best  to  collect  the  night  urine  as 
distinct  from  that  passed  in  the  day.  Thus,  the  patient  on 
going  to  bed  empties  his  bladder,  and  all  urine  passed 
during  the  night  including  that  voided  on  rising  in  the 
morning,  is  the  night  urine  ;  whilst  all  urine  passed  sub- 
sequently, up  to  the  time  of  going  to  bed  is  considered  the 
day  urine.  In  many  cases,  as  we  shall  presently  learn, 
it  is  an  advantage  to  collect  the  day  urine  in  separate  lots, 
as  the  forenoon  and  evening  portions. 

(4)  Should  any  difficulty  arise  preventing  the  collection 
of  the  twenty-four  hours'  urine,  or  that  of  the  day  and  night 
period ;  then  the  patient  must  be  directed  to  bring  with 
him  two  samples,  the  one  passed  fasting,  the  other  about 
two  hours  after  the  principle  meal  of  the  day.    That  passed 


50  DISEASES    OF    THE    KIDNEY. 

the  first  thing  on  rising,  and  the  after  dinner  urine  is  the 
hest  for  this  purpose. 

(5)  When  we  are  unahle  to  obtain  the  twenty-four  hours' 
urine,  and  a  quantitative  estimation  is  made  of  the  con- 
stitutents,  we  are  of  course  unable  to  ascertain  the  absolute 
amount  of  the  substance  passed  into  the  urine  in  the  twenty- 
four  hours,  but  only  the  percentage  amount.  This,  if  we 
have  taken  the  specific  gravity  of  the  urine,  often  affords 
us  a  valuable  indication,  though  of  course  it  is  not  so  satis- 
factory as  when  the  absolute  amount  can  be  calculated. 
But  unless  that  precaution  is  taken  a  mere  percentage 
estimation  is  valueless,  indeed  it  is  worse  than  valueless 
it  is  misleading,  for  instance,  to  say  that  a  sample  of  urine 

/  contains  1'9  per  cent,  of  urea  means  nothing,  but  if  we  say 
that  a  sample  of  urine  with  a  specific  gravity  1-020  con- 
tains 1-9  per  cent.,  we  imply  that  the  proportion  of  urea 
in  relation  to  the  other  solids  is  low ;  whilst  a  urine  with 
a  specific  gravity  1-012,  which  has  a  percentage  of  1-9  of 
urea,  indicates  that  this  substance  is  relatively  in  excess  of 
the  other  solids. 

(6)  No  definite  conclusion  should  ever  be  drawn  from 
the  examination  of  a  single  sample  of  urine  passed  within 
twenty-four  hours.  Owing  to  the  neglect  of  this  rule 
many  mortifying  errors  in  diagnosis  have  occurred,  and 
positive  statements  have  been  made  which  have  subse- 
quently required  modification. 

10.    Variations    in    the    Quantity    of    Urine. 

Relation  of  the  Urinary  Water  to  the  Solids. — The  mean 
average  quantity  of  urine  passed  by  a  healthy  adult 
in  the  twenty-four  hours  may  be  stated  at  fifty  fluid 
ounces,  of  which  close  on  950  grains,  about  two  ounces,, 
is  solid  matter.  If  French  measures  are  used,  as  they 
generally  are  now  for  the  calculations  of  urinary  analysis. 


VARIATIONS    IN    THE    QUANTITY    OF    UEINE.  51 

then  the  amount  may  be  roundly  expressed  as  1450  cubic 
centimeters,  of  which  58  grms.  are  sohd  matter.  Thus 
it  will  be  seen  that  solids  constitute  very  nearly  four  per 
cent,  of  the  urinary  secretion.  A  knowledge  of  this  fact 
enables  us  to  employ  a  very  simple  formula  to  express  the 
relationship  of  the  solids  to  the  water  of  the  urine  in  any 
given  case.  This  formula  ccmsists  in  doubling  the  two 
last  figures  of  the  specific  gravity  of  the  fluid.  For  since 
we  know  that  specific  gravity  bears  a  constant  relationship 
to  the  amount  of  solids  present  in  a  fluid,  any  variation  in 
their  amount  will  cause  a  variation  in  the  specific  gravity. 
And  frequent  determinations  have  shown  that  whilst  four 
per  cent,  of  solids  is  the  approximate  yield  on  evaporation, 
1*020  is  the  mean  average  specific  gravity  of  the  normal 
twenty-four  hours'  urine  taken  at  a  temperature  of  60°  F. 
So  that  if  we  have  ascertained  the  quantity  of  urine  passed 
in  the  twenty -four  hours  and  its  specific  gravity,  we  have 
no  difficulty  in  determining  whether  the  solids  on  any  given 
day  are  increased  or  decreased.  Thus,  in  the  case  of  normal 
urine,  the  individual  has  passed  1450  c.c.  in  the  twenty- 
four  hours  and  the  specific  gravity  is  1'020,  then  by  multi- 
plying the  two  last  figures  of  the  specific  gravity  by  two,  we 
have  forty  grms.,  the  amount  of  solid  matter  in  1000  c.c. 
in  other  words  exactly  four  per  cent.,  and  to  find  the 
amount  for  the  whole  period  is  simply  a  matter  of  propor- 

,.         ,,         1450  X  20  X  2 

tion,    inus   —    —  58  grms.  of  sohd  matter 

passed  with  the  urine  in  twenty-four  hours. 

This  CO- efficient,  which  was  originally  suggested  by 
Trapp,  gives  very  close  results,  but  care  should  be  taken 
when  employing  it,  to  observe  the  temperature  at  which 
the  specific  gravity  is  taken,  since  every  difference  of  7°  F. 
from  the  temperature  at  which  the  instrument  was . 
graduated,  represents  a  difference  of  one  degree   in  the 

E  2 


52  DISEASES    OF    THE    KIDNEY. 

registration  of  the  urinometer.  It  is  necessary  therefore 
either  to  record  the  temperature,  or  else  make  the  correc- 
tion for  the  variation  at  the  time  of  observation.  Again 
as  urinometers  often  differ  materially  from  each  other,  it  is 
important  when  making  a  series  of  observations,  for  com- 
parison, always  to  use  the  same  instrument. 

To  illustrate  the  practical  value  of  this  method,  the  follow- 
ing instance  may  be  taken.  The  collected  urine  of  twenty- 
four  hours  of  a  patient  suffering  from  chronic  renal  dis- 
ease amounts  to  1650  c.c,  and  has  a  specific  gravity  of 
1*016,  which  according  to  Trapp's  formula  gives  52-8  grms. 
of  sohd  matter  passing  out  by  the  kidneys  in  the  twenty- four 

1  rn         1650  X  16  X  2      ^rt  o  -vr         •» 

hours.     Thus =  52-8   grms.     Now  ii  we   co- 

1000  ^ 

agulate  the  albumin  by  boiling  and  filtering  it  off,  and 

when  cold  again  take  the  specific  gravity  of  the  filtered 

urine,  we  find  that  this  is  lower.      Suppose  it  has  lost  two 

degrees,  and  instead  of  a  specific  gravity  of  1-016  it  is  1-014, 

then  agaia  applying  Trapp's   formula  we   find  that  the 

urinary  solids,  minus  the  albumin,  amount  to  46-2  grms., 

1650x14x2  ^  ^g.2         g    Qj.  ;^2.8  grms.   less  than  the 

1000  ^ 

amount  of  urinary  solids  usually  passed  in  health  ;  whilst 
the  difference  between  the  two  specific  gravities,  1-016  and 
1-014,  roughly  represents  the  amount  of  albumin  passed 
out  of  the  system  in  the  twenty-four  hours.  In  cases 
where  the  specific  gravity  of  the  urine  is  above  1-025  it  is 
advisable  to  use  Hseser's  co-efficient  2-33. 

Under  ordinary  cu-cumstances  we  rely  entirely  on  the 
urinometer  to  give  us  an  estimate  of  the  amount  of  sohds 
present  in  urine,  but  in  some  cases,  however,  the  amount  ob- 
tained is  so  small,  that  we  are  unable  to  float  the  instrument 
freely  in  the  secretion.  We  may  then  either  dilute  the  urine 
with   distilled  water,   multiplying  the  last  figure  of  the 


VARIATIONS    IN    THE    QUANTITY    OF   URINE.  53 

specific  gravity  of  the  mixed  fluids  by  their  united  volume. 
Thus  if  we  add  to  half  an  ounce  of  urine,  one  and  a  half- 
ounce  of  distilled  water,  we  have  four  volumes,  one  of 
urine  and  three  of  water,  and  the  specific  gravity  of  this 
mixture  is  1'007,  then  7x4  gives  the  specific  gravity  of 
the  unmixed  urine  as  1-028.  Or  the  specific  gravity  bottle 
may  be  used,  which  gives  the  weight  of  the  urine  as  com- 
pared with  that  of  an  equal  quantity  of  distilled  water  at  a 
standard  temperature.  For  this  purpose  a  bottle,  fitted 
with  a  glass- stopper,  constructed  to  hold  25  or  50  grms. 
of  distilled  water,  measured  at  15°  C.  to  a  mark  on 
its  neck,  is  filled  with  urine.  The  bottle  and  its  contents 
are  then  weighed,  at  a  temperature  of  15°  C,  which  is  ob- 
tained by  plunging  the  bottle  into  hot  water,  if  the  tem- 
perature is  lower  than  this,  or  into  ice  cold  water  if  higher. 
The  weight  obtained,  subtracted  from  the  empty  bottle, 
when  multiplied  by  4  if  25  c.c,  or  by  2  if  60  c.c,  of  urine 
have  been  used,  gives  the  specific  gravity  in  hundreds. 
When  very  accurate  determinations  are  required,  or  only 
extremely  small  quantities  of  urine  are  available,  it  may 
be  necessary  to  evaporate  the  urine  to  dryness  in  a  small 
platinum  capsule  and  weigh  the  residue.  For  cHnical  pur- 
poses however,  this  will  hardly  ever  be  necessary,  and  as 
the  process  can  only  be  performed  in  the  laboratory,  and 
only  with  accuracy  then  by  persons  thoroughly  trained  to 
analytical  operations,  the  details  of  the  process  need  not 
be  given  here.  For  the  examination  of  the  urine  of 
patients  at  their  own  homes,  the  practitioner  will  find  the 
specific  gravity  beads,  a  very  useful  substitute  for  the 
urinometer  which  owing  to  its  fragility  is  apt  to  get  broken. 
One  of  these  beads,  which  arenumbered  5,10,  15,  20,  25,  30 
respectively,  is  placed  in  the  urine,  say  one  numbered  15,  if 
this  sinks  then  the  next  highest  number  is  used,  if  this  lat- 
ter floats,  then  we  read  the  specific  gravity  as  ranging  be- 


54  DISEASES    OF    THE    KIDNEY. 

tween  1*015  and  1-020.  On  the  other  hand  if  the  first  bead 
floats,  we  add  the  bead  next  lowest  in  number,  if  this 
sinks,  then  we  read  the  specific  gravity  as  between  1*010 
and  1-015,  and  so  on. 

The  clinical  indications  afforded  by  the  observation  of 
the  relations  subsisting  between  the  urinary  water  and  the 
solids,  as  obtained  by  measurement  of  the  twenty-four 
hours'  urine  and  the  specific  gravity,  are  numerous  and 
important.  For  not  only  does  the  procedure  yield  a  clue 
in  many  cases  to  the  nature  of  the  disease,  but  it  gives  us 
important  information  as  to  the  extent  of  the  tissue 
metabolism  going  on  in  the  body.  The  following  are 
some  of  the  more  important  results  to  be  obtained  by  such 
observations. 

(1)  Urinary  water  increased,  specific  gravity  greatly  dimin- 
ished.— When  the  specific  gravity  is  much  reduced  (1-002- 
1*005)  we  have  the  condition  known  as  hydruria,  such  as 
occurs  temporarily  in  hysteria  or  under  great  nervous  ex- 
citement, or  permanently  in  diabetes  insipidus.  When 
only  moderately  reduced  (1-010)  if  tolerably  constant,  an 
early  stage  of  granular  kidney  may  be  suspected,  especially 
if  the  pulse  exhibits  signs  of  tension,  even  if  albumin  is 
not  even  yet  detected.  Some  forms  of  glycosuria  may 
also  be  attended  with  a  profuse  flow  of  urine  of  low  specific 
gravity.  These  cases  are  often  associated  with  temporary 
albuminuria,  and  thie  sugar,  the  quantity  of  which  is  not 
great,  often  intermits  with  uric  acid  deposits.  Considerable 
excretion  of  urine  of  low  specific  gravity,  frequently  occurs 
in  persons  in  a  low  state  of  health,  in  these  cases  the  de- 
ficiency in  the  amount  of  solids  passed,  is  due  to  deficiency 
of  urea.     This  condition  is  termed  anazoturia. 

(2)  Urinary  water  increased,  sj^ecijic  gravity  normal  or  only 
slightly  diminished. — This  condition  is  found  whenever  there 


VARIATIONS    IN    TllE    QUANTITY    OF   URINE.  55 

is  increased  tissue  metabolism  going  on  in  the  body  unat- 
tended with  pyrexia,  it  is  appropriately  termed  j^olyuria,  for 
though  the  specific  gravity  of  the  urine  is  not  increased, 
still  it  is  not  greatly  diminished  in  proportion  to  the  quan- 
tity of  water.  Thus  the  patient  passes,  say  3200  c.c.  of 
urine  in  the  twenty- four  hours  of  a  specific  gravity  of  1*015, 

then  by  Trapp's  formula =96  grms.  of  solid 

•^        ^^  1000 

matter   are  excreted,    as  compared  with  58  grms.  which 

represents    the   normal    excretion   of    that    period.    The 

whole  of  the  urinary  solids  may  be  increased,  sometimes 

only  one  or  two  constituents.     When  due  to  an  increase  of 

urea  we  have  the  conditions  described  by  Prout  as  azo- 

turia  ;    when  the  phosphates  are  in  excess,  then  the  case 

may  be    considered   to   be  one    of    those    described    by 

Tessier  under  the  term  "  phosphatic  diabetes." 

(3)  Urinary  water  increased,  with  increase  of  specific 
gravity. — Points  of  course  to  diabetes  mellitus,  or  an  exag- 
gerated form  of  the  preceding  condition. 

(4)  Urinary  water  normal,  specific  gravity  lessened. — Sir 
Andrew  Clark  has  described  a  condition  which  he  con- 
sidered due  to  "renal  inadequacy"  in  which  the  urea  is 
very  deficient.  It  seems  however  to  differ  little  from 
Willis's  class  anazoturia,  except  that  there  is  no  marked 
increase  of  the  urinary  water. 

(5)  Urinary  water  lessened,  with  increased  specific  gravity. — 
This  is  a  condition  which  accompanies  all  pyrexial  states, 
and  is  especially  marked  in  those  attended  with  profuse 
sweating  as  in  rheumatic  fever  ;  or  with  diarrhoea.  Asso- 
ciated with  albuminuria  it  is  the  condition  of  urine  met 
with  in  acute  and  in  early  stages  of  chronic  tubal  ne- 
phritis. In  certain  cases  of  irritative  dyspepsia  with 
increased  tissue  metabolism,  the  amount  of  solids  passed 
by  the  urine  is  increased.     Murchison  observing  how  often 


56-  DISEASES    OF    THE    KIDNEY. 

urates  (lithates)  were  deposited  from  such  urines,  believed 
the  condition  was  caused  by  the  excessive  formation  of 
uric  acid  in  the  body,  lithcemia,  and  that  the  urine  being 
saturated  with  its  salts  they  were  deposited.  (See 
Lithuria). 

11.  Reaction.  — The  reaction  of  normal  urine  is  acid. 
The  average  degree  of  acidity  of  the  twenty-four  hours' 
urine  is  equivalent  to  about  two  grms.  of  oxaUc  acid, 
that  is  to  say,  the  urine  requires  so  much  sodium  hydrate 
to  neutralize  it  as  would  be  required  to  neutraUze  two 
grms.  of  oxahc  acid.  It  is  on  this  fact  that  the  quanti- 
tative estimation  of  the  acidity  of  the  urine  is  based.  A 
solution  of  sodium  hydrate  is  made  by  dissolving  6"35  grms. 
of  pure  caustic  soda  in  distilled  water,  filling  up  to  one 
litre.  One  cubic  centimetre  of  this  solution  represents 
•01  grms.  of  oxahc  acid.  This  solution  is  to  be  gradu- 
ally added  from  a  burette  to  100  c.c.  of  urine  placed 
for  the  purpose  in  a  beaker  or  glass  vessel,  till  the  exact 
point  of  neutralisation  is  hit,  which  is  shown  by  blue 
litmus  paper  ceasing  to  be  reddened,  and  red  Htmus  is  not 
blued.  Now  if  4-5  c.c.  of  the  solution  is  required  for  this 
neutrahsation,  then  the  acidity  of  100  c.c.  of  urine  cor- 
responds to  0-045  grms.  of  oxalic  acid,  and  from  this  the 
acidity  of  any  amount  of  urine  can  be  calculated  by  pro- 
portion. The  acidity  of  the  urine  varies  however  greatly 
at  different  periods  of  the  day,  being  influenced  by  various 
physiological  circumstances.  These  variations  are  tolerably 
constant  and  regular,  so  that  writers  speak  of  the  increase 
and  decrease  of  the  acidity  as  the  acid  and  alkaline  tide. 
The  following  table  compiled  from  observations  made  by 
myself,  will  show  the  nature  and  extent  of  this  ebb  and 
flow. 


REACTION    OF    URINE. 


57 


Time. 

TOTiL    ACID    AS 

Acidity   per    hour  as 

OXALIC  ACID. 

OXALIC     ACID. 

11  p.m.  to    8 

a.m.* 

1'14  grms. 

0'12  grms. 

8  a.m.  to  1 L 

a.m. 

021      „ 

0  07       ,, 

11  a  m.  to     1 

p.m.* 

0-40      „ 

0-20      „ 

1  p  m.  to    4 

p.m. 

Oil      „ 

003      „ 

4  p.m.  to    7 

p.m.* 

0-29      „ 

0-09      „ 

7  p.m.  to  11 

p.m. 

0  07     „ 

002      „ 

*  Breakfast,  8.30  a.m.     Lunch,  1  p.m.     Dinner,  7  p.m. 


The  causes  producing  these  variations  have  been  differ- 
ently assigned.  Dr.  Bence  Jones  thought  the  depression 
in  the  acidity  of  the  urine,  corresponded  to  the  withdrawal 
of  acid  from  the  circulation  to  supply  the  acid  for  the  gas- 
tric secretion.  Dr.  Eoberts  on  the  other  hand  beheves  the 
depression  is  caused  by  the  entrance  of  the  newly  digested 
food  into  the  blood,  and  as  he  points  out  that  the  normal 
alkalescence  of  the  blood  is  due  to  the  preponderance  of 
alkaline  bases  in  articles  of  diet,  a  meal  is  therefore  equi- 
valent to  a  dose  of  alkali.  I  have  also  pointed  out  that 
the  depression  also  occurs  at  a  time  when  the  elimination 
of  carbonic  acid  is  most  active,  viz.,  after  rising,  exercise, 
or  after  a  meal.  The  acid  reaction  of  the  urine  is  due 
mainly  to  the  presence  of  acid  sodium  phosphate,  and  to 
some  extent  to  the  acid  salts  of  uric  and  hippuric  acids. 
How  an  acid  secretion  like  urine  can  be  separated  from  an 
alkaline  fluid,  like  the  blood,  for  many  years  required  an 
explanation.  In  1874,  however,  I  demonstrated  the  fact 
that  if  we  take  a  weak  alkaline  solution  (5  per  cent.)  of 
two  salts  known  to  exist  in  the  blood,  viz.,  neutral  sodium 
phosphate  and  sodium  bicarbonate,  and  place  them  in  a  U 
tube,  fitted  with  a  diaphragm  at  the  bend,  and  au 
electrical  current  be  passed  through  the  fluid,  the  reaction  at 
the  positive  end  of  the  tube  becomes  acid,  whilst  that  at 


58  DISEASES    OF    THE    KIDNEY. 

the  negative  end  is  rendered  more  alkaline.      This  results 
from  the  decomposition  of  the  two  salts,  thus  : — 

Sodium  Bicarbonate.     Neutral  Phosphate.     Sodium  Carbonate.     Acid  Phosphate. 

NaHC03       +     Na^HPO^   =      Na3C03     +  NaH.PO^ 

The  explanation  of  the  paradox  of  the  alkaline  solution 
thus  yielding  an  acid,  is  due  to  the  fact  that  sodium  bicar- 
bonate is  in  reality  an  acid  salt,  although  it  has  an  alkaline 
reaction.  This  explanation  also  serves  to  explain  another 
paradox,  how  after  the  administration  of  certain  alkaline 
carbonates,  the  urine  becomes  more  alkaline,  which  has 
been  observed  both  by  Bence  Jones,  Beneke,  Parkes  and 
myself. 

The  acidity  of  the  urine  increases  gradually  after  it  has 
been  passed,  owing  partly  to  an  acid  fermentation  of  the 
mucus  and  pigmentary  matters,  and  partly  to  the  forma- 
tion of  acid  urates.  This  increase  of  acidity  is  chiefly 
noted  in  some  pathological  conditions,  especially  in  dia- 
betes and  in  febrile  urines.  The  maximum  is  reached  in 
from  three  to  four  days,  when  it  becomes  ammoniacal  from 
the  decomposition  of  the  urea.  The  increase  in  the  acidity 
and  its  nature  may  be  shown  by  employing  Bertholet's 
method  of  "  partage,"  which  is  based  on  the  fact  that 
mineral  acids  are  but  slightly  soluble  in  ether,  whilst  the 
organic  acids  are  readily  so.  Thus  if  we  estimate  the 
acidity  each  day  by  means  of  the  sodium  hydrate  solution, 
we  find  that  it  steadily  increases ;  but  if  in  addition,  we  agi- 
tate a  portion  of  the  urine  with  an  equal  bulk  of  ether,  and 
then  withdraw  the  etherial  solution,  we  shall  find  that  each 
day  the  etherial  solution  will  become  more  charged  with  acid 
than  on  the  previous  day.  The  reason  for  this  being,  that 
the  acidity  of  the  urine  was  at  first  due  almost  entirely  to 
acid  sodium  phosphate,  which  is  but  slightly  soluble  in 
ether,  whilst  as  fermentation  proceeds  organic  acids,  lac- 


HIGHLY   ACID    URINES. 


59 


tic  and  acetic  acids  are  formed,  which  are  readily  "xDarted  " 
by  the  ether  from  their  solution.  [Clinical  Chemistry, 
pp.  181-189). 

The  pathological  conditions  under  which  changes  in 
character  of  the  reaction  of  the  urine  varies,  may  be  con- 
sidered under  three  heads,  as  causing  : — 

(a)  Highly  Acid  Urines. 

(b)  Fixed  Alkaline  Urines. 

(c)  Volatile  Alkaline  Urines. 

(a)  Highly  acid  urine  may  be  due  either  to  absolute 
or  relative  increase  of  acid.  Acids  and  acid  salts 
are  as  is  well  known  continuously  entering  the  blood. 
(1)  They  may  be  introduced  into  the  body  from  with- 
out in  the  food.  The  quantity,  however,  thus  derived 
under  ordinary  conditions  is  comparatively  small,  since 
nearly  the  whole  of  the  saline  constituents  of  the  food  are 
alkaline,  or  become  so  by  conversion  in  the  system.  Still, 
a  small  quantity  of  acid  sodium  phosphate  is  derived  from 
the  juice  of  flesh,  and  this  passes  no  doubt  unchanged  into 
the  blood.  (2)  Acid,  too,  is  generated  in  the  alimentary 
canal  from  fermentative  decomposition  of  the  saccharine 
matters  taken  with  the  food,  or  of  the  amylaceous  princi- 
ples that  have  been  converted  into  sugar.  In  health  this 
fermentative  process  is  most  active  at  the  lower  part  of 
the  small  intestines,  and  in  the  first  portion  of  the  large 
intestine.  (3)  Lastly,  acid  is  generated  in  the  tissues  of 
the  body.  Thus,  in  a  condition  of  inactivity  the  lymph 
fluid  of  all  tissues  is  alkaline  or  neutral ;  on  activity  being 
evoked  the  reaction  becomes  acid.  This  is  well  seen  in 
what  follows  the  contraction  of  muscles,  in  which  the  con- 
traction wave  gives  rise  to  sarcolactic,  carbonic,  and  other 
volatile  fatty  acids,  and  probably  glycerin-phosphoric  acid. 
Of  these  acids  the  carbonic  passes  directly  into  the  blood 
in  a  free  state.      With  regard  to  the  other  acids,  their  dis- 


60  DISEASES    OF    THE    KIDNEY. 

tribution  and  combination  with  the  inorganic  bases,  like- 
wise set  free  by  the  process  of  tissue  oxidation,  is  so 
highly  comphcated  that  little  is  known  about  them. 

The  acid  thus  formed  in  the  body  is  discharged  from 
the  system  by  three  channels,  (1)  by  the  lungs,  (2)  the 
skin,  (3)  the  urine.  Acid  is  also  removed  from  the 
stomach  by  the  gastric  juice,  but  as  this  is  neutrahsed 
by  the  soda- salts  of  the  bile  and  pancreatic  juice,  it 
need  not  be  considered  as  a  channel  of  discharge,  ex- 
cept perhaps  under  very  abnormal  conditions,  when  it  is 
poured  out  as  acid  vomit  under  circumstances  of  (reflex) 
"  irritability. 

So  long  as  the  discharge  of  acid  from  the  system  passes 
off  regularly,  and  is  distributed  in  normal  proportion 
among  the  secretions  concerned  in  its  removal,  its  presence 
on  the  mucous  surfaces  with  which  it  comes  in  contact  is 
unfelt.  When,  however,  the  production  of  acid  is  exces- 
sive, or  the  distribution  of  the  acid  among  the  various 
secretions  is  kregular,  so  that  one  becomes  more  highly 
charged  with  acids  than  the  others,  then  the  secondary 
effects  due  to  "acidity  "make  themselves  manifest.  These, 
when  the  formation  of  acid  is  only  slightly  in  excess,  or  is 
only  temporarily  induced  by  casual  disturbances,  may  be 
limited  to  shght  heartburn  in  the  case  of  the  stomach, 
some  itching  or  nettle-rash  of  the  skin,  a  little  bronchial 
catarrh,  or  some  degree  of  irritability  of  the  urinary 
passages.  When,  however,  the  formation  of  acid  is  ex- 
cessive or  long- continued,  the  secondary  diseases  it  gives 
rise  to  become  formidable  in  their  nature.  Attacks  of 
acute  dyspepsia,  accompanied  with  paroxysms  of  pain, 
cramp,  vomiting,  and  diarrhoea,  so  severe  and  often  so 
long- continued  as  to  reduce  the  patient  to  the  utmost 
stage  of  prostration.  Intractable  skin  diseases,  like  lepra, 
psoriasis,  and  eczema,  severe  asthmatic  paroxysms,  and 


HIGHLY   ACID    URINES.  61 

chronic  bronchitis,  frequent  attacks  of  gravel  and  other 
renal  and  urinary  affections.  Excessive  formation  of  acid, 
determined  probably  by  certain  textural  and  neurotic 
conditions,  is  very  likely  the  cause  of  the  severe  inflam- 
mation of  the  structures  in  and  around  joints,  such  as  we 
witness  in  gout  and  in  attacks  of  acute  rheumatism.  An 
over-acid  state  may  also  be  considered  a  predisposing 
cause  of  diabetes,  since  glycosuria  may  be  temporarily  in- 
duced by  the  injection  of  dilute  acid  into  the  portal  system  ; 
whilst  the  discharge  of  large  quantities  of  highly  acid 
urine,  which  takes  place  day  after  day,  shows  that  the 
production  of  acid  in  the  body  is  excessive. 

These  are  the  most  palpable  and  direct  manifestations 
of  an  outburst  of  an  over- acid  state,  but  there  are  many 
other  ailments,  such  as  palpitations  and  flutterings  of  the 
heart ;  exaggerated  pulsations  of  large  arteries  ;  irregu- 
larities and  intermissions  of  the  pulse  ;  aching  pains  in 
the  limbs  ;  burning  patches ;  neuralgia  ;  megrim  ;  ver- 
tigo; noises  in  the  ears ;  depression  of  spirits ;  sleeplessness, 
&c. ;  which  many  writers  describe  as  arising  from  irregular 
manifestations  of  the  gouty  state,  and  which  Dr.  Murchison, 
with  an  equal  show  of  reason,  refers  to  functional  disorder 
of  the  liver,  but  which,  without  committing  ourselves  to 
any  definite  theory,  may  be  conveniently  considered  as 
arising  quite  as  frequently  from  an  accumulation  of  acid 
"in  the  system. 

The  acidity  of  the  urine  may  be  increased  relatively, 
owing  to  concentration  of  the  urine,  thus  in  hot  weather 
owing  to  increased  action  of  the  skin,  the  amount  of  urin- 
ary water  is  lessened  and  consequently  the  degree  of  acidity 
rises ;  similarly  in  pyrexia,  especially  rheumatic  fever,  and 
in  diarrhoea.  This  relative  increase  may  not  only  be 
caused  by  a  diminution  of  the  water  excreted,  but  from 
deficiency  of  the  alkaline  phosphates  ;    this  condition   is 


62  DISEASES    OF    THE    KIDNEY. 

frequently  met  with  in  the  urines  of  ill-nourished  or  stru- 
mous children. 

(b)  Fixed  alkaline  urine  is  due  to  the  excessive  elimina- 
tion of  the  carbonates  of  potash  and  soda.  The  alkales- 
cence is  termed  fixed,  because  the  blue  stain  given  to  red 
htmus  is  permanent.  Such  urine  is  generally  cloudy  when 
passed,  from  precipitated  phosphates,  which  are  insoluble 
in  alkaline  solutions.  These  urines  often  contain  an  ex- 
cess of  calcium  phosphate,  which  will  form  an  abundant 
deposit  (see  Phosphates,)  and  uric  acid,  but  frequently  the 
excess  of  the  alkahne  carbonates  is  the  only  morbid  condi- 
tions to  be  noted  with  regard  to  them.  The  conditions  that 
lead  to  the  passage  of  alkahne  urine,  containing  an  excess  of 
alkahne  carbonates,  may  be  thus  summarised,  (aj  Grene- 
ral  debihty  and  the  feebleness  with  which  the  respu-atory  act 
is  performed,  leading  to  the  accumulation  of  carbonic  acid  in 
the  system.  With  regard  to  this  point,  it  is  interesting  to 
note  that  urine  alkaline  from  the  presence  of  carbonates  of 
the  fixed  alkahes  is  frequently  met  with  in  patients  con- 
valescing from  acute  diseases.  (bj  Diminished  secretion 
of  bile,  which  is  the  frequent  result  of  the  duodenal 
catarrh  produced  by  the  irritation  of  the  acid  contents  of 
the  stomach  being  poured  into  the  intestines,  gives  rise  to 
an  accumulation  of  alkaline  carbonates  in  the  blood,  the 
bile  being  the  chief  secretion  by  which  alkahne  salts  are 
removed  from  the  body ;  for  though  a  portion  of  them  are 
undoubtedly  reabsorbed  into  the  blood  from  the  intestines, 
a  considerable  proportion  of  them  are  discharged  with  the 
faeces.  Obstruction,  therefore,  to  the  discharge  of  bile 
leads  to  their  retention  in  the  blood,  and  consequently 
being  ehminated  in  greater  quantity  by  the  kidney.  (c) 
The  acids  formed  by  fermentative  changes  being  of  the 
fatty  acid  series ;  these  on  entering  the  system  are  oxidised 


ALKALINE    URINE.  63 

into  carbonic  acid,  and  thus  uniting  with  the  bases  of  the 
alkaline  oxides  form  carbonates  of  these  bodies,  and  by  in- 
creasing the  alkalescence  of  the  blood  will  diminish  the 
natural  acidity  of  the  urine  and  even  render  it  alkaline. 

This  form  of  alkaline  urine  is  chiefly  met  with  in 
debilitated  persons,  and  those  suffering  from  flatulent 
dyspepsia,  especially  that  affecting  the  small  intestines. 
It-  is  associated  with  tolerably  distinct  features,  such  as 
loss  of  weight,  weariness,  irregularity  of  bowels,  flatu- 
lence, frequent  micturition,  more  or  less  sallowness  of 
complexion,  great  despondency,  urine  alkaline  or  else 
neutral  or  faintly  acid,  depositing  phosphates  on  boiling, 
and  effervescing  on  the  addition  of  dilute  acid. 

(cj  Volatile  alkaline  urine  is  caused  by  the  presence  of 
ammonium  carbonate,  the  result  of  the  decomposition  of 
urea.  It  is  termed  volatile  because  the  blue  stain  given 
to  red  Htmus  disappears  on  drying.  When  the  urine  is 
alkaline  from  the  presence  of  volatile  alkali,  we  have  in 
addition  to  the  deposit  of  calcium  phosphate  of  lime, 
crystals  of  ammonio-magnesium  phosphate.  The  am- 
moniacal  condition  of  the  urine  is  due  to  a  ferment 
(micrococcus  urece  J  which  can  be  isolated  by  filtration ;  it 
consists  of  spherical  globules  which  settle  at  the  bottom 
of  the  vessel  and  appear  to  increase  by  budding.  The 
decomposition   that  occurs   may  be  thus  represented: — 

Urea.  Water.  Ammonium  Carbonate. 

CHAO    +    2H2O       =       (NHJ^COg 

This  ammoniacal  fermentation  of  the  urea  takes  place  in 
the  urine  only  after  its  secretion  by  the  kidneys,  and  does 
not  occur  in  normal  urine  unless  it  becomes  mixed  with 
the  products  of  decomposition  from  the  mucus  of  the  genito- 
urinary tract,  or  the  ferment  introduced  into  the  bladder 


64  DISEASES    OF    THE    KIDNEY. 

by  dirty  catheters,  or  the  urine  already  alkahne  from  fixed 
alkah  is  received  into  dirty  chamher  vessels. 

The  iridescent  film  which  is  so  often  found  on  the  sur- 
face of  the  urine,  consists  of  a  pellicle  composed  chiefly  of 
calcium  phosphate  and  crystals  of  ammonio-magnesium 
phosphate.  It  often  has  no  clinical  significance  beyond 
the  fact,  that  the  urine  has  been  received  into  a  utensil 
■which  has  not  been  properly  cleaned.  For  if  we  take  a 
sample  of  normal  urine  of  acid  reaction  and  divide  it  into 
two  portions  and  place  them  both  in  beakers,  each  of 
which  contains  a  drop  of  stale  urine,  and  then  render  the 
portion  in  one  of  the  beakers  alkaline  with  liquor  potass^e, 
ureal  decomposition  will  set  in  very  much  earlier  in  the 
beaker  containing  the  alkalised  urine  than  in  the  one  per- 
mitted to  retain  its  normal  acid  reaction,  and  crystals  of 
triple  phosphate  speedily  form.  Dr.  Owen  Eees  has  ad- 
vanced a  theory  that  it  is  by  no  means  necessary  for 
ammoniacal  urine  to  depend  on  the  decomposition  of  urea  ; 
he  maintains  it  can  be  formed  by  the  secretion  of  the 
mucous  membrane,  which  owes  its  alkalinity  to  fixed 
alkali,  and  which,  mixed  with  the  urine,  unites  with  the 
acids  of  the  ammoniacal  salts  and  sets  free  ammonia. 
In  answer  to  this,  it  is  sufficient  to  state  that  the  exis- 
tence of  ammoniacal  salts  in  urine,  except  as  the  result  of 
the  decomposition  of  urea  has  been  denied  by  most 
chemists,  and  moreover  if  this  view  were  correct,  am- 
moniacal urine  would  be  more  frequent  than  it  is,  since 
whenever  the  mucous  secretion  of  the  urinary  passages 
was  increased,  the  urine  would  become  ammoniacal. 
Clinical  experience  teaches  us  that  this  is  not  the  case, 
though  there  can  be  but  little  doubt  that  the  presence  of 
alkali  greatly  favours  ureal  decomposition,  and  the  pro- 
cess is  induced  more  rapidly.  The  experiments  of  Feltz 
and  Eitter  have  proved  incontestably,  that  two  factors  are 


COLOUR    OF    UEINE.  65 

required  for  the  production  of  ammoniacal  urine ;  viz.,  a 
previously  diseased  state  of  the  genito-urinary  organs  and 
the  introduction  of  the  special  ferment.  In  all  catarrhal 
conditions  of  the  urinary  surfaces,  ureal  decomposition  will 
readily  occur  on  the  introduction  of  the  organism,  but  the 
most  characteristic  is  that  attendant  on  the  catarrh  fol- 
lowing lesions  of  the  spinal  cord. 

12.  Colour. — Healthy  human  urine  is  best  described 
as  amber  coloured,  that  is  yellow  with  just  a  tinge  of  red. 
It  is  only  recently  that  the  nature  of  the  pigments  which 
impart  this  colour  to  urine,  has  been  rendered  at  all 
definite  though  still  there  are  many  points  in  dispute. 
The  following  will  express  the  views  at  present  held 
on  the  subject,  without  entering  into  the  questions  under 
discussion.  The  pigmentary  matters  of  the  urine  are  de- 
rived from  two  sources  :  1.  From  the  colouring  matter  of 
the  blood  by  the  reduction  of  hasmatin  in  the  liver,  under 
the  action  of  the  bile  acids,  by  which  the  bile  pigments 
are  formed,  and  these  by  absorption  from  the  intestines  are 
discharged  by  the  urine  as  urobilin  or  choletelin.  2.  From 
indol,  which  is  probably  derived  from  the  decomposition 
of  proteid  substances  by  pancreatic  digestion.  Indol 
being  absorbed  by  the  intestines  is  converted  into  indican 
in  the  alkaline  blood,  in  which  form  it  appears  in  the 
urine.  With  regard  to  the  relative  quantities  of  the  two 
pigments,  urobilin  is  more  abundant  in  healthy  urine  than 
indican,  which  sometimes  may  not  be  present  at  all.  In 
morbid  urines,  however,  the  reverse  generally  obtains  and 
indican  is  abundant  and  gives  rise  to  several  important 
reactions. 

(1)  Urobilin  was  first  separated  by  Jaffe  from  nor- 
mal urine,  it  corresponds  to  the  pigment  obtained  by 
E.  Maly,  by  dissolving  bilirubin  in  dilute  soda  ley  and 
adding  sodium  amalgam,  air  being  excluded,  and  which  he 


66  DISEASES    OP    THE    KIDNEY. 

termed  hydro-bilirubin.  MacMunn  by  passing  nitrous 
vapours  into  an  alcoholic  solution  of  bilirubin,  obtained  a 
final  oxidation  product  wbicli  be  has  named  choletelin,  and 
wbicb  be  believes  to  be  a  further  oxidation  product  of  uro- 
bilin. For  all  practical  purposes  they  may  be  assumed  to  be 
identical,  at  all  events  the  term  urobilin  is  the  most  ap- 
licable  to  the  pigment  derived  by  the  oxidation  of  the  bile 
pigments  and  which  appears  in  the  urine.  All  authorities 
are  agreed  with  regard  to  the  derivation  of  these  pigments. 
In  the  first  place  hsematin  is  formed  by  the  action  of  the 
bile  acids  on  hemoglobin,  and  bilirubin  is  formed  ;  this  is 
oxidized  in  the  intestines  into  urobilin  and  this  absorbed 
into  the  blood  is  discharged  by  the  urine,  (according  to 
MacMunn,  urobilin  is  further  oxidised  in  the  intestines 
and  enters  the  blood  as  choletelin  in  which  form  it  is 
ehminated) . 

UrobHin  as  obtained  either  directly  from  bilu'ubin,  or 
from  the  urine,  presents  the  following  characters.  It  is 
a  brownish  red  powder  soluble  in  alcohol,  ether,  and 
chloroform.  It  gives  no  play  of  colour  with  nitric  acid 
which  distinguishes  it  from  bilh'ubin.  In  acid  solutions, 
when  sufficiently  dilute,  it  gives  a  broad  band  extend- 
ing from  6  to  a  little  beyond  f  ;  in  alkaline  solutions  the 
band  is  less  refrangible.  Its  presence  in  urine  may  be 
shown  by  adding  ammonia  till  the  urine  is  alkaline,  filter- 
ing, and  to  the  filtrate  adding  a  few  drops  of  zinc  chloride 
when  a  green  fluorescence  wiU  be  observed,  especially  if 
the  filtrate  be  rendered  dilute.  If  the  urine  contains  any 
bile  pigments  these  must  first  be  separated  by  milk  of 
lime  and  carbonic  acid.  The  composition  of  urobihn  is 
given  as  C32H44N4O7,  its  relationship  to  bilirubin  being 
shown  by  the  following  reaction  : — 

Bilirubin.  Urobilin. 

2  (CieHisN.Oa)  +  H,0  -f  He  =  C3.H^N,0, 


COLOUR    OF    URINE.  67 

The  iiroliasmatin  of  G.  Harley,  the  urochrome  of 
Thudichum,  the  urophain  of  Heller  are  probably  all 
bodies  allied  to  urobilin,  modified  perhaps  by  the  dif- 
ferent modes  of  preparation.  Urobilin  is  the  most  pro- 
minent pigment  in  healthy  urine,  and  according  to  some 
is  the  only  normal  pigment.  Its  quantity  is  increased  in 
febrile  conditions,  in  organic  and  functional  derangements 
of  the  liver,  in  valvular  disease  of  the  heart,  and  in 
anaemia. 

Stokvis  (iV.  Bep.  Pharm.,  xxi.,  123)  has  described  another 
pigment  derived  from  the  oxidation  of  bile  pigment ;  and 
which  according  to  MacMunn  only  appears  in  urine  when 
there  is  grave  disturbance  of  the  system  and  in  disease  of 
severe  character.  It  differs  from  urobilin  in  being  insoluble 
in  ether  and  chloroform,  and  not  forming  insoluble  com- 
pounds with  lead  acetate.  It  is  soluble  in  dilute  acids,  water, 
and  alcohol.  Its  solutions  are  light  yeUow,  these  when 
rendered  alkaline  and  boiled  with  reducing  agents,  yield  a 
beautiful  rose  colour  which  gives  a  spectrum  of  a  broad 
band  in  green.  In  thick  strata  the  band  begins  close  to  d 
and  extends  to  b.     In  thin  strata  the  band  falls  short  of  b. 

(2)  Indican.  Although  some  have  maintained  that  indican 
is  not  j)resent  as  the  normal  colouring  matter  of  urine, 
still  there  are  few  healthy  urines,  when  treated  with  strong 
hydrochloric  acid,  that  do  not  give  the  characteristic  red- 
dish violet  reaction,  though  only  faintly.  The  quantity, 
however,  is  greatly  increased  in  •  many  forms  of  disease. 
Indican,  which  corresponds  with  Heller's  uroxanthin,  is 
probably  derived  from  indol,  one  of  the  products  of  pan- 
creatic digestion,  and  is  met  with  in  the  intestinal  canal 
and  in  the  faces.  A  small  portion  of  this  indol  (CgHgN) 
absorbed  into  the  blood  is  probably  converted  into  indican 
(C52H62N20g4)  by  the  alkaline  salts  of  that  fluid,  traces 
of  which  escape  by  the  urine.     Should  the  quantity  of 

f2 


68  DISEASES    OF    THE    KIDNEY. 

indol  formed,  or  absorbed,  be  increased,  there  is  also  a 
proportionate  increase  in  the  amount  of  indican  observed 
in  the  urine. 

To  show  its  presence,  place  4  c.c.  of  strong  nitric  or 
hydrochloric  acid  in  a  test  tube  and  gently  heat,  then 
float  an  equal  quantity,  of  urine,  freed  from  albumin, 
on  the  surface,  when  a  ring  will  develop  at  the  point  of 
contact,  which  is  violet  if  only  little  indican  is  present, 
and  more  distinctly  blue  if  there  be  much.  To  separate 
this  as  a  chloroform  solution,  mix  the  acid  and  urine  to- 
gether, add  a  few  drops  of  chloride  of  lime  solution  till  a 
greenish  tinge  is  perceptible,  then  agitate  with  10  c.c.  of 
chloroform  and  set  aside.  The  chloroform  will  separate 
out  tinged  of  a  bluisli  or  violet  hue,  according  to  the 
amount  of  indican  present. 

The  amount  of  indican  is  increased  in  hot  weather,  pro- 
bably from  the  concentration  of  the  urine.  A  meat  diet 
has  the  same  effect.  It  is  increased  in  diabetes  mellitus, 
Addison's  disease,  cancer  of  the  stomach,  typhoid  fever, 
dysentery,  and  the  reaction  stage  of  cholera.  In  obstruc- 
tion of  the  intestines  the  quantity  is  greatly  increased, 
owing  as  Senator  has  observed,  to  this  condition  favouring 
the  absorption  of  indol.  Urines  containing  indican  are 
generally  acid  and  contain  an  excess  of  uric  acid,  they 
also  frequently  have  a  slight  reducing  action  on  Fehling's 
solution,  either  from  the  excess  of  uric  acid  or  from  the 
presence  of  indiglucin,  though  the  presence  of  this  sub- 
stance is  disputed.  The  blue,  green,  and  red  urines 
occasionally  met  with  in  disease  are  generally  suj)posed 
to  be  indican  in  different  stages  of  oxidation,  forming 
pigments  designated  by  the  terms  urrhodin  and  uroery- 
thrine.  Indigo  has  been  met  with  as  a  constituent  of 
urinary  calculus  or  as  a  deposit.  Dr.  Ord  (Path.  Soc. 
Trans.,  vol.  xxix.,  p.  157)  accounts  for  its  presence  by  the 


COLOUR    OF    URINE.  69 

fact  of  the  indican  in  the  urine  being  converted  into 
indigo  by  contact  with  highly  acid  urine. 

In  addition  to  the  increase,  or  variation  of,  these  nor- 
mal pigments,  the  urine  in  disease  may  be  coloured  by  the 
presence  of  blood,  bile,  melanotic  deposit,  or  by  many 
articles  of  food  or  medicine. 

Blood  is  of  course  most  readily  detected  by  the  presence 
of  the  red  corpuscles,  and  the  characteristic  spectrum  of 
oxyhaemoglobin  of  two  bands,  one  near  d,  the  other  near  e, 
changed  to  one  broad  band  between  d  and  e,  by  the 
action  of  reducing  agents.  However  slight  the  haemor- 
rhage, even  if  not  sufficient  to  give  a  decided  colour  to  the 
urine,  blood  corpuscles  will  be  observed  unless  decom- 
position has  destroyed  them.  Their  presence  in  fresh 
urine  distinguishes  between  haematuria  and  haemoglobin- 
uria,  in  which  latter  case  they  are  dissolved  before  they  are 
passed.  In  this  form  of  haemorrhage,  however,  there  is 
generally  in  addition  a  third  band  noticed  in  the  spectrum, 
between  o  and  d,  known  as  methsemoglobin  (see  Hsemoglo- 
binuria).  Small  quantities  of  blood,  1  in  1500,  will  give  to 
urine  a  smoky  tinge.  When  present  in  more  considerable 
quantities  the  tint  varies  and  is  much  affected  by  the 
reaction,  acid  urines,  with  an  equal  amount  of  blood,  giv- 
ing a  darker  tint  than  alkaline.  The  urine  of  hsemoglo- 
binuria  is  characterized  by  a  deep  port  wine  or  ruby 
colour. 

Bile.  The  general  tests  for  bile  are  given  further 
on,  where  we  consider  bile  among  the  abnormal  pro- 
ducts that  may  appear  in  the  urine ;  here  reference 
will  only  be  made  to  the  spectroscopic  appearances 
of  some  of  the  modified  bile  pigments  as  they  may 
appear  in  urine.  The  bile  pigments  are  bilirubin,  bili- 
verdin,  and  bilifuscin ;  of  these  bilirubin  is  the  chief,  the 
other  two  being  formed  from  it  by  the  assumption  of 


70  DISEASES    OF    THE    KIDNEY. 

water,  thus— bilirubin  dgHigNaOa  +  H2O  +  0  =  deS-J^iO^ 
biliverdin  ;  and  bilifuscin  is  bilirubin  plus  one  atom  of 
water.  None  of  these  pigments  give  any  spectrum  unless 
acted  upon  by  reagents.  We  have  already  mentioned 
how  bilirubin,  converted  into  urobilin  in  the  intestines, 
appears  in  the  urine  a-s  its  normal  colouring  matter,  and 
have  described  its  spectrum-.  A  similar  change  occurs 
when  bilirubin  is  abnormally  present,  as  in  icteric  urine, 
by  adding  strong  nitric  acid  containing  a  few  drops  of  free 
nitrous  acid  (Gmehn's  test  for  bile).  At  first  when  we 
examine  this  reaction  by  the  spectroscope,  we  find  the 
solution  gives  a  broad  shading  in  orange  and  yellow,  and 
a  broad  baud  at  f.  As  oxidation  proceeds  this  shading 
clears  up  and  the  band  alone  is  visible  extending  from  b 
to  a  little  beyond  f,  the  spectrum  of  urobilin  which  has 
been  formed  by  the  action  of  acid  on  the  bilirubin. 
Another  bile  spectrum  of  great  interest  in  urinary  patho- 
logy, is  that  yielded  by  the  bile  acids  by  Pettenkoffer's 
test.  This  according  to  MacMunn  gives  a  band  outside 
D  and  a  broad  band  at  e. 

Melanin  is  sometimes  met  with  in  urine,  occurring  in 
persons  suffering  from  melanotic  cancer,  and  in  the  urine  of 
persons  after  repeated  attacks  of  ague.  One  of  the  best 
examples  that  have  come  under  my  notice  was  a  deposit 
passed  by  an  infant,  a  few  weeks  after  birth  and  shortly 
before  its  death,  and  which  was  sent  me  for  examination. 
I  was  unable  to  learn  if  there  was  any  special  clinical 
indication,  and  no  post-mortem  was  made.  Melanin  de- 
posits from  urine  in  minute  lumpy  granules  which  are 
soluble  in  liquor  potass^,  the  alkaline  solution  being  de- 
colorised by  passing  a  stream  of  chlorine  through  it. 
Melanin  may  be  distinguished  from  carbon  granules,  coal 
dust,  or  soot,  which  may  be  mixed  with  urine  for  purposes 
of  deception,  by  the  fact  that  these  latter  are  insoluble 
in  liquor  potassse. 


COLOUR    OF    URINE.  71 

■  Extraneous  colouring  matters.  Many  substances  taken 
as  food  or  medicine  may  colour  the  urine  temporarily. 
They  are  chiefly  vegetable  colouring  matters  such  as  de- 
rived from  beet-root,  carrots,  whortle  berries,  logwood, 
senna,  rhubarb,  santonin,  turmeric,  etc.,  and  can  readily 
be  distinguished  by  the  alterations  affected  in  the  colour 
when  treated  with  acids  and  alkalies.  The  salicylates 
when  administered,  impart  a  smoky  tint  to  urine,  so  does 
carbolic  acid  when  absorbed  from  wounds,  the  presence 
of  these  substances  is  detected  by  the  blue  colour  given 
by  their  solutions  with  ferric  chloride.  With  saHcylic 
acid,  it  is  sufficient  to  add  a  few  drops  of  ferric  chloride 
directly  to  the  urine.  To  separate  carbolic  acid,  the  urine 
should  be  acidulated  with  hydrochloric  acid  and  the  mix- 
ture distilled,  the  distillate  gives  with  ferric  chloride  a  blue 
colour  (p.  87) .  In  carboHc  acid  poisoning  the  sulphates  dis- 
appear from  the  urine,  being  converted  into  sulpho-carbo- 
lates.  Dr.  Maguire  {Brit.  Med.  Journal,  Oct.  25,  1884)  has 
pointed  out  that  certain  brown  urines  which  occur  abnor- 
mally, are  often  due  to  the  presence  of  pyrocatechin  and 
protocatechuic  acid  formed  in  the  body,  probably  from 
compounds  of  the  aromatic  group  resulting  from  pancrea- 
tic digestion.  If  these  do  not  undergo  their  proper  trans- 
formation in  the  system,  they  are  eliminated  as  the  above 
named  substances.  They  are  probably  identical  with 
the  substance  called  alkapton.  The  urines  containing 
them  may  be  at  first  light- coloured  and  become  brown 
by  exposure,  in  others  the  brown  colour  is  observed  from 
the  first. 

Although  the  colour  of  normal  urine  for  twenty-four 
hours  when  mixed  may  be  described  as  amber  coloured, 
still  individual  samples  passed  during  that  period,  vary 
considerably  in  shade.  Thus  the  morning  urine,  urina 
sanguinis,  is  more  red  than  yellow,  whilst  after  the  inges- 


72  DISEASES    OF    THE    KIDNEY. 

tion  of  large  quantities  of  fluid  it  is  more  or  less  straw  col- 
oured. In  disease  the  variation  of  the  colour  often  affords 
a  very  valuable  indication  as  to  the  nature  of  many  dis- 
eases, the  colour  should  therefore  always  be  noted  in 
clinical  records. 


Yaeiation  of  Normal  Constituents. 

13.  Urea,  CH4N2O. — This  substance  can  be  obtained 
pure  from  the  urine,  by  first  precipitating  the  phosphates 
and  sulphates  with  a  saturated  solution  of  barium  nitrate 
(1  vol.)  and  barium  hydrate  (2  vols.)  and  filtering  them 
off,  and  then  evaporating  the  filtrate  to  a  syrupy  consis- 
tence, and  treating  this  residue  with  nitric  acid,  sp.  gr. 
1*25.  Crystals  of  urea  nitrate  are  thus  formed,  these  are 
decomposed  by  boihng  with  a  solution  of  barium  car- 
bonate, and  evaporating  the  mixture  again  to  a  syrupy 
consistence.  This  is  then  treated  with  boUing  alcohol  and 
the  solution  filtered  whilst  hot  through  animal  charcoal. 
The  filtered  solution  is  then  concentrated ;  on  cooling 
crystals  of  pure  urea  will  be  formed.  These  crystals  form 
four- sided  prisms  and  are  extremely  soluble  in  cold  water, 
their  solution  is  neutral  to  test-paper.  A  drop  of  this 
solution  placed  on  a  glass  shde  and  touched  with  a  drop 
of  nitric  acid,  gives  rise  to  a  white  shining  precipitate  con- 
sisting of  rhombic  plates  of  iirea  nitrate ;  similarly  with 
oxalic  acid  we  get  a  white  precipitate  of  iirea  oxalate.  A 
solution  of  mercuric  nitrate  in  alkaline  solutions  of  lU'ea 
forms  an  insoluble  compound  (CH^N^O,  4HgO).  Hypo- 
bromous  acid  and  hypochlorous  acid  decompose  urea  into 
water,  carbonic  acid  and  nitrogen.  It  is  upon  these  reac- 
tions that  the  methods  for  the  quantitative  estimation  of 
m-ea  are  based. 


■DREA. 


73 


The  quantitative  estimation  of  urea  is  described  in  the 
appendix,  whilst  here  is  given  approximate  methods  of 
determining  the  amount  of  urea  sufficiently  accurate  for 
clinical  purposes. 

A.  HypoMorite  Process.  A  simple  and  rehable  method 
of  approximately  estimating  the  amount  of  urea  in  urine 
has  been  devised  by  Dr.  Squibb,  New  York,  and  has  been 
introduced  by  Mr.  Martindale  to  the  notice  of  practitioners 
in  this  country  [Brit.  Med.  Jour.,  Nov.  1884).  It  is  so 
simple  that  the  apparatus  can  be   constructed  in  a  very 


Fig   4. — Squibb's  Apparatus. 

short  time,  and  so  portable  that  it  can  be  readily  carried 
by  the  clinical  clerks  round  the  wards  during  the  visit  of  the 
physician.  It  consists  of  two  wide-necked  vials,  a  and  b 
(see  fig.  4) ,  joined  together  by  a  piece  of  india-rubber  piping. 
In  A,  which  is  allowed  to  stand  upright,  is  placed  the  urine, 
and  the  solution  to  effect  the  decomposition.  The  cork  of 
B  is  fitted  with  two  glass  tubes,  one  communicating  with  a 
by  means  of  the  india-rubber  tubing,  c  ;  the  other,  which 
acts  as  an  overflow  pipe,  is  turned  down  so  that  the  overflow 


74  DISEASES    OF    THE    KIDNEY. 

may  discharge  into  a  graduated  measuring  glass,  d  ;  b  is 
filled  with  water.  Finally,  b  laid  on  its  side  is  placed  on  a 
book  or  block  of  wood,  so  that  laying  flat  its  lowest  side  is 
on  a  straight  line  with  the  neck  of  a.  All  being  ready  40  c.c. 
of  solution  of  chlorinate  of  soda  ( United  States  Pharviacopoeia) 
are  introduced  into  a,  and  4  c.c.  of  urine  are  placed  in  a 
small  tot  or  beaker,  f,  which  is  carefully  introduced  into 
A  by  means  of  a  pair  of  forceps  so  that  the  urine  does  not 
mix  with  the  chlorinated  solution.  The  measuring  glass 
(d)  to  receive  the  displaced  water,  is  then  rinsed  out  with 
water  so  as  to  leave  the  inner  surfaces  as  wet  as  they  will 
be  left  when  it  is  emptied  for  measurement.  The  stopper  is 
now  taken  out  of  the  overflow  tube,  and  when  the  few  drops 
of  water  which  follow  its  withdrawal  have  ceased,  the  tube 
is  placed  in  the  receiving  glass.  The  vial,  a,  is  now  inclined 
so  that  the  chlorinated  solution  comes  thoroughly  in  con- 
tact with  the  urine.  Effervescence  ensues  and  nitrogen 
gas  passes  over  into  b  displacing  the  water  which  flows 
into  the  receiving  jar.  When  no  further  discharge  of  gas 
occurs  the  process  is  over.  The  apparatus  is  then  al- 
lowed to  stand  a  short  time  for  the  temperature  to  adjust 
itself  to  that  of  the  room,  during  which  time  a  little  water 
will  pass  up  from  the  receiving  glass  back  into  b.  When 
this  movement  ceases,  the  measurements  can  be  made. 
Now  each  cubic  centimeter  of  wa.ter  displaced,  is  equal  to 
a  cubic  centimeter  of  gas  that  displaced  it — and  as  a 
c.c.  of  nitrogen  equals  -0027  gramme  of  urea,  therefore 
the  number  of  c.c.  of  water  represents  the  number  of 
times  -0027  gramme  of  urea  is  contained  in  4  c.c.  of  urine. 
But  it  is  more  simple  to  obtain  the  percentage  from  1  c.c. 
of  urine,  and  therefore  the  number  of  c.c.  of  dis^jlaced 
water  is  divided  by  4.  Then  this  number  being  multi- 
pUed  by  -0027  gives  the  percentage  of  urea  in  the  urine. 
For  example,   suppose  the  displaced  water  from  4  c.c.  of 


UREA.  75 

urine  to  be  36  c.c.  This  divided  by  4  gives  9  c.c.  for  each 
1  c.c.  of  urine.  Then  9  times  -0027  is  -0243  or  -0243 
grm.  for  1  c.c.  of  urine,  or  2-43  grms.  per  cent.  Now  if 
the  patient  has  passed  1200  c.c.  of  urine  in  the  twenty- 
four  hours,  it  is  easy  with  these  data  to  find  out  the  total 
diurnal  excretion  of  urea,  for  1200  c.c.  x  "0243  grm.  = 
29  "16  grms.  the  amount  of  urea  in  the  twenty-four  hours. 

The  merit  of  this  method  is  its  simplicity  and 
handiness.  That  it  is  absolutely  accurate  is  not  con- 
tended for,  but  in  that  respect  it  does  not  compare 
unfavourably  with  other  clinical  methods,  and  is  to 
all  intents  and  purposes  quite  as  accurate  as  the  hypo- 
bromite,  or  the  soda-lime  processes.  Its  advantages  over 
the  former  lie  in  the  fact  that  the  chlorinated  solution  is 
more  stable  than  the  hypobromite  and  also  that  the  ap- 
paratus is  more  portable,  whilst  the  simplicity  of  the  pro- 
cedure gives  it  an  immense  advantage  over  the  latter.  A 
simple  and  fairly  reliable  process  for  the  clinical  estima- 
tion of  urea  was  greatly  to  be  desired,  and  with  such  an 
apparatus  estimations  of  the  amount  of  urea  in  urines 
ought  now  to  become  as  much  a  matter  of  routine  as  the 
testing  for  sugar  and  albumin. 

B.  Hypobromite  Process  is  based  on  the  fact  that  hypobro- 
mous  acid  decomposes  urea  into  water,  carbonic  acid,  and  ni- 
trogen. The  latter  gas  is  measured  as  follows  : — A  flask  of 
about  300  c.c.  capacity  is  fitted  with  tightly- fitting  perfor- 
ated cork,  and  attached  by  means  of  india-rubber  tubing 
to  a  graduated  tube  filled  with  water.  Place  in  the  flask, 
a,  25  c.c.  of  hypobromite  of  soda  (100  grms.  of  sodium 
hydrate  dissolved  in  260  c.c.  of  water,  and  the  cold  solu- 
tion mixed  with  25  c.c.  of  bromine),  at  the  same  time 
place  in  the  flask  a  small  test-tube  containing  5  c.c.  of 
urine,  taking  care  that  the  contents  of  the  test-tube  do 
not  as  yet  mix  with  the  hypobromite  solution.     Now  at- 


76 


DISEASES    OF    THE    KIDNEY. 


taeh  the  flask  to  the  graduated  cyHnder,  b.  Then  tilt  the 
flask  so  that  the  urine  in  the  test-tube  may  freely  mix 
with  the  hypobromite.  The  reaction  now  begins,  and  the 
gas  depresses  the  water  in  the  graduated  tube  forcing  it 
into  reservou-,  c;  in  about  five  minutes  the  process  is 
complete,  and  the  amount  of  gas  standing  in  the  gradu- 
ated tube  can  be  read  off,  having  seen  that  the  water 
in  both  tubes  is  level.  If  the  tube  is  graduated  so  that 
each  measure  represents  one  gramme  of  urea  in  100  c.c. 
of  urine,  then  to  calculate  the  quantity  in  the  twenty-four 
hours  is  only  a  matter  of  proportion. 


Fig.  5. 


-Gerrard's  Apparatus. 

In  employmg  this  test  for  the  determination  of  urea  in 
diabetic  urine,  it  must  be  remembered  that  grape  sugar 
increases  the  quantity  of  nitrogen  evolved  from  urea  by 


UEEA.  77 

sodium  liypobromite,  or  the  chlorinated  solution  by  quite  7 
per  cent.  The  deficiency  of  nitrogen  yielded  with  a  pure 
solution  of  urea  under  the  hypobromite  or  hypochlorite  pro- 
cess, is  about  8  per  cent.,  the  addition  of  glucose,  therefore 
brings  it  up  to  the  theoretic  yield.  This  is  of  very  little  im- 
portance unless  the  analyses  are  made  for  the  purpoee  of 
comparing  a  diabetic  with  a  non-saccharine  urine.  It 
must  also  be  remembered  that  the  nitrogen  evolved  by 
the  process  does  not  come  entirely  from  the  urea,  but  also 
from  the  other  nitrogenous  constituents,  uric  acid,  and 
kreatinin,  it  has  therefore  been  proposed  to  deduct  4*5  per 
cent,  from  the  total  amount  calculated  to  correct  this 
error.  But  as  the  yield  of  nitrogen  from  urine  is  deficient 
by  at  least  7  per  cent.,  the  error  is  more  than  sufficiently 
covered. 

In  health,  the  daily  average  excretion  of  urea  for  an  adult 
weighing  10|-  stone  may  be  taken  as  33-5  grms,  about 
3  per  cent.,  or  if  English  measures  be  employed,  535 
grains,  or  rather  more  than  an  ounce.  For  every  addi- 
tional pound  in  the  weight  of  the  body  it  is  usual  to  add  3i- 
grains.  This  holds  good  up  to  a  certain  weight,  but  is 
certainly  too  high  for  very  heavy  persons  who  have  ceased 
growing,  and  too  low  for  young  active  individuals.  I  there- 
fore adopt  the  following  scale  in  calculating  the  normal 
excretion  of  different  weights  including  childhood  and 
youth ;  thus  from  40  to  60  lbs.,  I  consider  4^  grains  of 
urea  to  each  pound  of  the  body- weight  to  represent  the 
normal  excretion  ;  from  60  to  120  lbs.,  4  grains  ;  from 
120  to  160  lbs.,  31  grains;  160  to  175  lbs.,  3i  grams; 
175  to  196- lbs.,  3  grains.  Thus  a  child  of  five  years  of 
age  weighing  40  lbs.  would  daily  excrete  180  grains  (11-7 
grms.  of  urea).  A  lad  of  twelve  weighing  80  lbs.  would 
excrete  320  grains  (20-7  grms.)  ;  a  young  adult  weighing 
117  lbs.  would  excrete  535  grains  (33-2  grms.) ;  whilst  a 


78  DISEASES    OF    THE    KIDKEY. 

fully  grown,  middlo-aged  adult  weighing  185  lbs.  would 
excrete  555  grains  (36  grms.)  of  urea. 

In  disease,  the  quantity  of  urea  eHminated  in  the 
twenty- four  hours  may  be  steadily  increased  or  diminished, 
whilst  often  sharp  fluctuations  are  observable.  These 
fluctuations  are  accounted  for  by  the  fact  that  in  health 
the  amount  of  urea  excreted  is  proportionate  to  the 
metabolism  of  the  nitrogenous  elements  of  the  food  that 
have  been  converted  into  tissue,  in  disease  no  such  rela- 
tionship is  maintained. 

Urea  is  increased  in  all  conditions  of  pyrexia,  and  this 
increase  is  closely  connected  with  the  rise  of  temperature. 
The  connection  between  the  increased  urea  and  the  rise 
of  temperature  can  be  readily  understood  if  the  recent  ex- 
planation of  the  febrile  process  be  accepted.  Formerly  it 
was  held  that  tissue  changes  depended  on  the  amount  of 
oxygen  taken  in  by  the  lungs,  so  that  on  increased  respira- 
tion a  more  intense  combustion  took  place,  and  metabolism 
was  increased  with  the  production  of  more  carbonic  acid 
and  urea,  whilst,  when  respiration  was  impeded,  oxida- 
tion was  imperfectly  performed,  and,  as  a  consequence, 
many  of  the  intermediary  products,  as  oxalic  acid,  uric 
acid,  etc.,  were  not  burnt  off,  but  were  eliminated  in  an 
imperfectly  oxidised  condition.  It  is  upon  this  view  that 
most  of  the  chemico-pathological  speculations  at  present 
held  are  based.  But  the  view  is  now  gaining  ground  that 
the  cells  are  to  a  certain  extent  independent  of  the  amount 
of  oxygen  supplied  to  them  by  respiration  ;  that  is  to  say 
though  they  originally  obtain  oxygen  by  the  process  of 
respiration,  they  are  able,  so  to  speak,  to  stow  it  away, 
and  make  use  of  it  independently  under  certain  vital  con- 
ditions which  bring  about  intramolecular  changes  in  their 
composition,  so  that  reduction  is  a  prior,  or  at  least  a 
simultaneous,  process  with  oxidation.     According  to  this 


UEEA.  79 

view,  instead  of  increased  metabolism  being  the  result  of 
increased  oxidation,  it  is  the  increase  of  the  intra-molecu- 
lar  action  in  the  cells  themselves  that  occasions  the  de- 
mand for  oxygen,  and  a  more  active  condition  of  circula- 
tion and  respiration.  Accordingly,  in  fever,  the  earhest 
step  is  the  increase  of  intra-molecnlar  changes  in  the  cells 
themselves,  under  the  stimulus  probably  of  the  zymotic 
poison  ;  for  "when  the  stored-up  oxygen  is  exhausted,  then  a 
demand  for  a  fresh  supply  causes  an  increased  frequency 
of  pulse  and  respiration,  which  continues  so  long  as  the 
stimulus  (zymotic)  acts  on  the  cells  and  maintains  this 
abnormal  intra-molecular  activity.  The  fact  of  the  gra- 
dual and  steady  increase  of  the  pulse,  respiration  and 
temperature,  together  with  increased  excretion  of  urea 
during  the  early  stages  of  febrile  action,  gives  support  to 
this  view. 

Considerable  increase  in  the  amount  of  urea  excreted, 
occurs,  however,  without  pyrexia,  as  in  Prout's  cases  of  azo- 
turia  (see  Polyuria).  In  these  cases  we  must  suppose  the 
cells,  under  the  influence  of  the  nervous  system,  are  under- 
going intra-molecular  changes  with  morbid  activity,  and 
so  leading  to  increased  tissue  metabolism.  In  this  condi- 
tion the  process  stops  short  of  pyrexia,  and  we  have  only 
reduction  without  increased  oxidation.  The  excretion 
of  urea  is  diminished  in  nearly  all  chronic  affections 
also  unaccompanied  by  pyrexia.  In  diseases  of  the  liver 
accompanied  by  considerable  destruction  of  liver  sub- 
stance, as  in  cancer,  cirrhosis,  or  abscess  of  that  organ, 
the  amount  of  urea  excreted  is  generally  very  considerably 
diminished.  In  acute  yellow  atrophy  of  the  liver,  an  increase 
is  noted  in  the  early  stages,  but  as  the  fatty  degeneration 
advances  it  becomes  considerably  diminished,  though  as 
the  amount  of  urine  passed  is  very  small,  the  percentage 
amount  of  urea  may  appear  high.     Eapidly  growing  can- 


80  DISEASES    OF    THE    KIDNEY. 

cer  likewise  causes  a  diminution.  In  Bright's  disease  the 
excretion  is  diminished,  this  is  partly  owing  no  doubt  to 
diminished  formation  in  the  system  generally,  but  chiefly 
to  retention ;  since  the  amount  of  urea  found  in  dropsical 
exudations,  often  nearly  amounts  to  that  found  in  the 
urine.  As  the  dropsy  disappears,  so  we  find  correspond- 
ing increase  in  the  elimination  of  urea  in  the  urine. 

In  diabetes  mellitus  the  urea  is  considerably  increased, 
partly  owing  to  the  animalized  diet  and  partly  from  in- 
creased metabolism.  A  sudden  fall  in  the  excretion  both 
in  nephritis  and  diabetes  is  an  unfavourable  sign,  and 
often  precedes  the  onset  of  uraemia  or  diabetic  coma. 
In  women  the  excretion  of  urea  is  very  variable,  it  is  in- 
creased before  and  after,  but  diminished  during,  the  men- 
strual periods. 

14.  Uric  Acid,  CgHiN^Og. — Uric  acid  is  separated  from 
urine  in  a  free  state  by  the  addition  to  it  of  strong  hydro- 
chloric acid.  The  crystals  are  deposited  as  rhombic  tablets 
of  very  variable  form  (fig.  6.}  these  are  highly  insoluble  in 


Fig.  6. — Uric  acid  crystals. 

water  (1  in  15,000  parts),  freely  soluble  in  alkahne  solutions, 
from  which  they  are  re-precipitated  by  the  addition  of  acid. 
A  solution  of  uric  acid,  or  its  salts,  evaporated  to  dryness, 


URIC    ACID. 


81 


and  the  residue  touched  with  nitric  acid  and  then  with 
ammonia,  developes  a  violet-red  (murexide)  coloration. 
Uric  acid  has  a  reducing  action  on  alkaline  cupric  solu- 
tions, it  can,  however,  be  distinguished  from  glucose  by 
the  fact  that  uric  acid  is  removable  by  precipitation  with 
lead  acetate,  whilst  glucose  is  not.  If  any  doubt  therefore 
exists  as  to  whether  the  reduction  is  caused  by  uric  acid  or 
sugar  in  any  given  case,  a  few  drops  of  lead  acetate  added 
to  the  urine,  and  the  copper  test  applied  to  the  filtered 
solution,  then  if  the  previous  reduction  was  due  to  uric 
acid  we  shall  now  have  no  action  on  the  copper  whilst  if  it 
was  due  to  sugar,  the  reduction  will  take  place  as  before. 

Uric  acid  is  di-basic  forming  neutral  and  acid  salts  with 
the  alkaline  and  earthy  oxides.  The  most  important  being 
the  acid  urates  of  sodium  and  ammonium. 

The  following  table  gives  some  of  the  chief  character, 
istics. 


Urates. 

Formula. 

Solubility 
IN  Water. 

Deposited  as 

Acid  Ammonium 

C5H3N4O3  (NH4) 

1-1600 

fAmorphous        or 
<    spiked    globular 

Neutral  Sodium 

C5H2N403Na2 

1-77 

L  masses. 
Nodular  masses. 

Acid  Sodium 

C5H3N403Na 

1-1200 

("Amorphous,  rare- 
i   ly  crystallized. 
C  Amorphous        or 
I  in  fine  needles. 

Pine  granules. 

Neutral  ■  Potas- 
sium 
Acid  Potassium 
Neutral  Calcium 

C5H2N4O3K2 

C5H3N4O3K 
C5H2N403Ca 

1-44 

1-800 
1-1500 

Acid  Calcium 

(CBHsN403)2Ca 

1-600 

C  Amorphous  or  in 
i   fine  needles. 

Acid  Lithium 

CsHsNiOsLi 

1-60 

C  Amorphous     and 
I   in  fine  needles. 

The  acid  ammonium  urate  is  found  as  a  constituent  of 
urinary  calculi,  and  as  a  deposit  in  alkaline  (volatile) 
urine.  The  neutral  sodium  urate  is  the  chief  salt  of  uric 
acid  in  normal  urine,  whilst  the  acid  salt  occurs  patho- 
logically as  a  constituent  of  urinary  ealcuh  and  gouty 
tophi,  in  the  latter  it  is  often  found  beautifully  crystallized. 


82 


DISEASES    OF    THE    KIDNEY. 


Tlie  potassium  urates  are  rarely  found  in  urinary  sedi- 
ments or  calculi,  the  acid  calcium  salt  is,  however,  more 
frequent.  Lithium  urate  is  next  to  the  neutral  potas- 
sium urate  the  most  soluble  of  all  the  salts  of  uric 
acid,  hence  the  advantage  of  the  administration  of  this 
base  in  gouty  and  calculous  affections.     When  an  acid  is 


,.^t* 


v.. 


Fig-  7. — a.  Amorphous  urates,   b.  Crystals  of  urate  of  soda.    c.  Hedgehog 
crystals  of  urate  of  ammonium,     d.  Nodular  masses  of  urate  of  soda. 


added  to  a  concentrated  solution  of  urates  a  white  gela- 
tinous precipitate  occurs.  This  in  the  case  of  a  solution 
of  neutral  urates  is  caused  by  the  separation  of  acid  urates, 
and  in  the  case  of  acid  urates  by  the  liberation  of  uric 
acid  in  an  hydrated  form.  This  point  is  deserving  atten- 
tion, because  in  testing  concentrated  urines  for  albumin 
with  nitric  acid,  or  x^icric  acid,  a  ring  either  of  acid  urates 
or  hydrated  uric  acid  may  be  formed.  It  is  distinguished, 
however,  from  coagulated  albumin  by  disappearing  when 
heated.  It  is  also  important  because  Prout  believed  that 
in  many  cases  hydrated  uric  acid  was  set  free  in  the 
tubuli  uriniferi  when  the  urine  was  secreted  in  a  highly 
acid  condition,  and  thus  might  become  the  x^ossible  nucleus 
of  acalculus. 


UBIC    ACID.  83 

The  amount  of  uric  acid  in  the  twenty-four  hours'  urine 
can  be  estimated  as  follows. 

Collect  the  urine  passed  in  the  twenty-four  hours  and 
measure.  Take  200  c.c.  and  add  20  c.c.  of  strong  hydro- 
chloric acid.  Set  aside  in  a  tall  urine-glass  for  twenty- 
four  hours  to  allow  the  uric  acid  crystals  to  separate. 
Dry  a  small  filter-paper  in  the  air-bath  at  100°  C.  and 
weigh.  Collect  the  crystals  on  this  filter  and  wash  them 
well  with  water  slightly  acidulated  with  HCl.  Dry  them 
with  the  filter  in  the  air-bath  and  weigh.  For  example, 
the  weight  of  the  dry  filter  is  0'27  gramme,  with  the  crys- 
tals when  dried  it  weighs  "42  gramme,  therefore  the 
weight  of  the  crystals  in  200  c.c.  of  urine  will  be  0*15 
gramme,  and  if  the  quantity  of  urine  passed  in  twenty-four 

hours  be  1010  c.c. :   then,- =0-757  grm. 

200  .  ^ 

If  the  specific  gravity  of  the  urine  be  below  1*015,  it  is 
necessary  to  concentrate  it  by  evaporating  the  urine  till 
the  specific  gravity  stands  at  1-020  ;  since  all  the  uric  acid 
will  not  crystallize  out,  if  the  urine  be  very  dilute. 

The  mean  average  quantity  of  uric  acid  daily  excreted 
with  the  urine  amounts  to  about  0-7  grms.,  or  0^5  grms. 
per  cent. ;  in  disease  it  may  amount,  in  rare  cases,  to  2 
grms.  In  healthy  blood  the  amount  is  so  unappreciable 
that  many  of  the  best  observers  deny  its  existence,  and  it 
is  only  in  gout  that  traces  of  it  can  be  obtained  from 
blood  serum.  The  fact  that  only  such  small  quantities 
are  obtained  from  the  urine  both  in  health  and  disease, 
has  considerably  modified  the  assumption  that  uric  acid 
is  one  of  those  substances  through  which  each  particle  of 
albumin  passes  before  it  is  thrown  out  of  the  body  as 
urea,  and  that  whenever  oxidation  is  imperfectly  per- 
formed, intermediate  substances  are  not  all  converted  into 
urea,  and  so  appear  in  the  urine.      Indeed,  on  the  other 

g2 


84  DISEASES    OF    THE    KIDNEY. 

hand,  the  view  is  gaining  ground,  that  in  mammalian 
animals,  who  excrete  urea  instead  of  semi-soHd  urates,  like 
birds,  reptiles,  insects,  etc.,  that  the  amount  of  uric  acid 
i'ormed  in  the  body  is  extremely  small,  and  that  urea  is 
derived  directly  from  conversion  of  the  cyanogen  com- 
pounds, and  from  the  transformation  of  leucin  and  krea- 
tin,  without  having  passed  through  the  form  of  uric  acid. 
In  health  it  is  considered  probable  that  the  extremely 
small  quantity  found  in  the  tissues  is  destroyed  as  soon 
as  formed,  since  no  appreciable  traces  can  be  found  in 
the  blood.  The  extremely  small  quantity  found  in  human 
urine  is  probably  not  derived  from  the  body  generally, 
but  is  one  of  the  products  of  the  metabolism  of  the  kidney, 
and  which  instead  of  being  destroyed  at  the  seat  of  for- 
mation, as  is  the  fate  of  uric  acid  in  other  parts  of  the 
body,  is  got  rid  of  more  economically  by  being  passed  off 
directly  with  the  secreted  urine.  In  gout,  the  only  dis- 
ease in  which  uric  acid  is  present  in  an  appreciable 
amount  in  the  blood,  it  is  probable  that  uric  acid  escapes 
destruction,  or  may  be  formed  in  such  excess  that  it  is  not 
all  destroyed.  From  the  organs  therefore,  where  the 
blood  current  is  active,  it  is  probably  swept  away  into  the 
general  circulation,  whilst  in  tissues  where  the  blood  cur- 
rent is  feeble  as  in  the  cartilages  of  the  joints,  of  the  ear, 
and  in  the  straight  portions  of  the  tubuli  uriniferi  it  remains 
as  a  deposit  in  the  form  of  sodium  urate.  Dr.  Latham 
(oj),  cit.)  believes  that  uric  acid  is  produced  from  glycocin 
formed  in  the  liver  from  the  glycocholic  acid  of  the  bile, 
which  is  converted,  not  into  urea  as  hitherto  supposed,  but 
into  a  hypothetical  amido  body,  this  body  passes  into  the 
circulation  and  when  it  reaches  the  kidney  is  conjugated 
with  urea,  and  ammonium  urate  is  formed. 

Deposits  of  uric  acid,  or  of  the  urates,  or  both  mixed  to- 
gether, occur  whenever  the  urine  becomes  concentrated, 


HIPPUEIC    ACID.  85 

or  its  acidity  rises.  Deposits  of  urates  are  chiefly  due  to 
the  former  cause,  consequently  we  find  them  present  in 
the  urines  of  pyrexia  ;  they  are  often  persistently  passed 
when  there  is  any  disturbance  of  tissue  metabolism, 
accompanied  by  an  increase  in  the  quantity  of  urea,  this 
condition  is  often  a  prelude  to  the  onset  of  constitu- 
tional disease  as  phthisis,  cancer,  etc.  Crystalline 
deposits  of  uric  acid  are  on  the  other  hand,  generally 
noticed  when  the  urine  attains  a  high  degree  of  acidity. 
It  does  not,  however,  follow  that  the  urine  passed  from 
the  bladder  need  exhibit  a  highly  marked  acid  reaction, 
since  as  Prout  pointed  out,  a  small  quantity  of  extremely 
acid  urine,  passed  at  one  period  of  the  day  may  set  free 
the  uric  acid  at  that  time,  whilst  the  subsequent  samples 
being  less  acid,  may  diminish  the  total  acidity  of  the 
urine  collected  in  the  bladder.  Excessive  acidity  of  the 
urine  may  be  caused  by  an  over  acid  state,  or  irregular 
discharge  of  acid  from  the  system  generally,  or  by  the 
withdrawal  of  the  alkaline  bases,  or  by  the  relative  in- 
crease in  the  normal  acidity  of  the  urine  by  concentration. 
(See  Lithuria). 

15.  Hippuric  Acid,  C9H9NO3. — Hippuric  acid  crystals 
as  obtained  from  urine  are  pointed  rhombic  prisms,  and 
may  be  mistaken  for  crystals  of  uric  acid,  or  even  triple 
phosphate.  They  are,  however,  soluble  in  alcohol,  which 
uric  acid  is  not,  whilst  their  not  dissolving  in  acetic  acid 
proves  that  they  are  not  crystals  of  triple  phosphate.  The 
separation  and  estimation  of  hippuric  acid  is  a  long  and 
tedious  process,  and  little  available  for  clinical  purposes, 
the  mode  of  procedure  is  therefore  not  given  here,  but  is 
referred  to  in  the  appendix. 

About  0-8  to  1  grm.  of  hippuric  acid  is  passed  with  the 
urine  in  the  twenty-four  hours.  The  excretion  is  greatly 
increased  in   diabetes,   with  it  is   said  a   corresponding 


86  DISEASES    OF    THE    KIDNEY. 

diminution  of  uric  acid,  and  in  most  febrile  affections.  It 
is  also  augmented  by  the  use  of  certain  vegetable  sub- 
stances, as  cranberries,  blackberries,  plums,  etc.  As 
hippuric  acid  contains  the  radical  of  benzoic  acid,  it  is  not 
surprising  that  the  administration  of  benzoic  acid  should 
lead  to  an  increase  of  hippuric  acid  in  urine.  According 
to  some  observers,  the  increase  of  hippuric  acid  is  accom- 
panied with  a  corresponding  decrease  of  the  uric  acid 
excreted,  and  therefore  benzoic  acid  and  benzoate  of  soda 
have  been  administered  with  the  view  of  checking  the  ten- 
dency to  the  deposition  of  urates  and  uric  acid,  but  it  has 
been  shown  by  Dr.  Cook  {Brit.  Med.  Journal,  July,  1883) 
that  the  benzoates  do  not  diminish  the  excretion  of  uric 
acid  but  only  prevent  its  crystallization.  Kiihne  has  ob- 
served that  benzoic  acid  given  to  patients  suffering  from 
disease  of  the  liver,  passed  unchanged  into  the  urine  in- 
stead of  being  converted  into  hij)puric  acid,  from  this  it 
has  been  assumed  that  the  place  of  transformation  of  the 
vegetable  aromatic  constituents  of  our  food  is  the  liver. 

16.  Other  org^anic  acids. — In  addition  to  uric  acid 
and  hippuric  acid,  traces  of  other  organic  acids,  chiefly  de- 
rived from  the  aromatic  acid  series,  may  be  found  in  most 
urines,  these  are  phenyhc,  damaluric,  damohc,  tauryhc, 
and  kryptophanic  acids.  Of  these  the  phemjHc  acid  is  the 
only  one  of  clinical  importance,  from  the  fact  of  its 
appearing  in  increased  quantity  in  the  urine  after  the 
administration  of  the  salicylates,  or  in  carbolic  acid  poi- 
soning. Urines  containing  an  abnormal  quantity  of  this 
acid  acquire  a  violet  colour  on  the  addition  of  ferric 
chloride,  the  solution  becoming  bluish  on  exposure,  and 
finally  acquiring  a  muddy  cloudiness.  A  chip  of  fresh 
firwood  moistened  in  dilute  hydrochloric  acid,  will  acquire 
on  exposure  to  strong  sun-light,  a  deep  blue  colour  if  a 
fair  amount  is  present  in  solution.      In  cases  of  carboHc 


ORGANIC    ACIDS.  87 

acid  poisoning,  it  may  be  necessary  to  obtain  it  from  the 
urine  for  more  definite  examination.  For  this,  about  100 
c.c,  of  the  urine  must  be  boiled  for  some  hours  with  an 
equal  quantity  of  lime  water.  The  precipitate  filtered  off 
and  the  filtrate  evaporated  to  about  25  c.c.  This  is 
strongly  acidulated  with  hydrochloric  acid,  and  the  mix- 
ture after  standing  twenty-four  hours  is  again  filtered. 
The  filtrate  is  then  distilled,  when  a  turbid  milky  liquid  is 
obtained,  this  by  repeated  rectification  yields  an  oily  yel- 
low coloured  liquid,  which  gradually  sinks  to  the  bottom 
of  the  vessel.  To  obtain  phenylic  acid  quite  pure,  this 
oily  fluid  must  be  subjected  to  fractional  distillation,  but 
this  for  practical  purposes  is  unnecescary,  it  being  suffi- 
cient to  prove  the  presence  of  phenylic  acid,  with  its  allied 
acids,  as  being  in  considerable  excess.  Benzoic  acid, 
CyHgOa,  may  be  found  occasionally  in  stale  urines,  but  as  it 
is  somewhat  volatile  and  passes  off  as  the  urine  evaj)orates, 
it  often  escapes  observation,  it  is  formed  from  the  decom- 
position of  the  hippuric  acid. 

Hippuric   Acid.  Glycocin.  Benzoic  Acid. 

C9H,N03  +  H^O  =  C^HsN.O  +  C.HeO^ 
Kiihne   has  shown  that  in  cirrhosis  of  the  hver  benzoic 
acid  administered   as  medicine,  may  pass  unchanged  into 
the  urine. 

Lactic  acid,  CsHgOg,  is  formed  in  normal  urine  after 
emission  as  the  result  of  acid  fermentation.  In  certain 
forms  of  dyspepsia  and  in  the  early  stage  of  rickets,  lactic 
acid  may  be  obtained  from  the  freshly  passed  urine.  It 
can  be  separated  by  evaporating  the  urine  to  one-fifth  its 
bulk,  at  a  temperature  a  little  below  100°  C,  and  then  fil- 
tering. To  the  filtrate,  baryta  water  is  to  be  added,  and  the 
mixture  filtered.  Then  acidulate  the  filtrate,  with  a  few 
drops  of  strong  sulphuric  acid,  and  distil.  The  residue 
after  distillation  is  to  be  shaken  with  alcohol  and  allowed 


Ob  DISEASES    OF    THE    KIDNEY. 

to  digest.  After  standing  some  time  the  alcoholic  solution 
is  to  be  filtered  off,  and  the  filtrate  mixed  with  milk  of 
lime  and  evaporated  to  dryness.  The  residue  is  dissolved 
in  water,  and  a  stream  of  carbonic  acid  gas  passed 
through  the  solution,  which  is  to  be  heated  to  100°  c. 
"When  the  solution  is  cold,  the  precipitate  must  be  re- 
moved by  filtration,  the  filtrate  evaporated  to  dryness,  and 
the  residue  dissolved  in  rectified  alcohol.  The  alcoholic 
solution  is  concentrated  and  set  aside,  in  a  day  or  so  crys- 
tals of  calcium  lactate  will  deposit. 

Oxalic   acid,  C2H2O4,   is  present   in   extremely  minute 
quantities  in  combination  with  potash,  soda,  and  lime.    It 
is,  however,  often  present  in  excess,  and  then  a  crystaUine 
deposit  of  calcium  oxalate,  CaC204,  is  thrown  down  from 
the    urine.        The   crystals   of    calcium   oxalate   assume 
various   shapes,   the    most    common    being    the    square 
letter  envelope  shape  or  octohedral,  and 
which  are  alone  characteristic.     When 
present  in  a  discoid  form,  or  as   dia- 
mond points,  or   as   dumb-bells,  their 
^character  must  be  determined  by  their 
chemical  reactions ;    they   are   insolu- 
ble  in   acetic   and   oxalic  acids  which 
distinguish  them  from  deposits  of  the 
earthy  phosphates,  whilst  they  are  solu- 
^^^■^--O^^^^^^eoi  i^ig    -^    mineral    acids,    which    distin- 
guishes them  from    anomalous   forms 
of  uric  acid  crystals.     Under  the  blow-pipe  the  crystals 
are  reduced  to  calcium  carbonate,  which  effervesce  on  the 
addition  of  dilute  acid. 

To  estimate  the  amount  of  oxalic  acid  in  urine  the  fol- 
lowing method  is  the  most  accurate.  The  urine  is 
rendered  alkaline  with  ammonia,  and  then  treated  with 
calcium  chloride  to  complete  precipitation.      The  whole  is 


KEEATININ. 


89 


next  evaporated  to  a  small  volume,  strong  alcohol  added, 
and  the  mixture  laid  aside  for  twelve  hours,  it  is  then 
filtered,  and  the  precipitate  washed  with  alcohol  and  ether. 
The  precipitate  is  subsequently  washed  with  water  and 
acetic  acid  in  succession  ;  the  residue  dissolved  in  hydro, 
chloric  acid,  filtered,  and  the  filtrate  first  made  alkahne 
with  ammonia  and  then  strongly  acid  with  acetic  acid. 
The  resulting  oxalate  of  lime  is  collected  on  a  filter, 
washed,  and  converted  into  caustic   lime  before  weighing. 

The  conditions  which  lead  to  the  formation  and  deposi- 
tion of  calcium  oxalate  from  the  urine,  will  be  considered 
in  the  section  which  treats  of  the  morbid  conditions  of  the 
urine,  dependent  on  derangements  of  digestion.  (See 
Oxaluria). 

Palmitic  acid,  CieHaaOg. — Minute  traces  of  a  saponifi- 
able  fatty  acid,  said  to  be  palmitic,  though  it  is  probably  a 
mixture  of  it  with  stearic  and  oleic  acids,  can  be  sepa- 
rated from  normal  urines.  In  fatty  degeneration  of  the 
kidney,  in  all  purulent  affections  of  the  urinary  passages, 
in  phosphaturia,  when  there  is  evidence  of  the  breaking  up 
of  the  phosphorised  fatty  elements  of  the  nerve  centres, 
this  saponified  fatty  acid  is  formed  in  increased  quantities. 
The  mode  of  separating  it  from  the  urine  is  described  un- 
der the  head  of  fatty  matters  in  urine. 

17.  Kreatinin,  C4H7N3O. — Kreatinin  may  be  obtained 
by  rendering  the  urine  (200  c.c.)  alkaline  with  milk  of  lime 
and  then  adding  calcium  chloride  till  a  precipitate  ceases 
to  be  formed.  The  precipitate  is  then  removed  by  filtra- 
tion, and  the  filtrate  evaporated  to  near  dryness.  The 
residue  is  heated  with  alcohol  (50  c.c),  and  the  alcoholic 
solution  after  standing  some  hours  is  evaporated  to  half 
its  bulk.  When  cold,  a  small  quantity  of  a  solution  of 
zinc  chloride  (specific  gravity  1-2)  is  to  be  added.  After 
standing  some  time  crystals  of  kreatinin  zinc  chloride  will 


90  DISEASES    OF    THE    KIDNEY. 

be  deposited.  These  are  to  be  boiled  with  an  excess  of 
hydrated  lead  oxide  for  some  hours,  the  solution  filtered 
through  animal  charcoal,  and  the  filtrate  evaporated. 
The  residue  is  then  treated  with  boiling  alcohol  (50  c.c), 
and  the  solution  concentrated  to  one-fourth  its  bulk.  On 
standing,  oblique  rhombic  prisms  of  kreatinin  will  be  de- 
posited. These  are  soluble  in  100  parts  of  alcohol.  It  is 
an  extremely  powerful  base,  giving  an  alkaline  reaction 
with  test-paper.  About  0-6  to  1"2  grm.  is  said  to  be  passed 
into  the  urine  in  twenty-four  hours.  It  is  apparently 
derived  from   the  decomposition  of  kreatin  in  the  blood. 

Kreatin  Kreatinin 

Nothing  positive  is  known  with  regard  to  the  clinical  or 
pathological  import  of  its  variations  in  disease,  though  from 
the  fact  that  it  is  derived  from  kreatin,  one  of  the  products 
of  muscle  decomposition,  we  might  look  for  an  increase  in 
the  early  stages  of  muscular  atrophy,  or  in  pyrexial  con- 
ditions accompanied  wdth  rapid  wasting. 

18.  Phosphates. — Phosphoric  acid  in  the  body  com- 
bines with  the  alkaline  oxides  of  potassium  and  sodium  to 
form  soluble  or  alkaline  phosphates,  and  with  the  earthy 
oxides  of  calcium  and  magnesium  to  form  the  insoluble  or 
earthy  phosphates.  The  former  being  extremely  soluble 
are  never  separated  from  the  urine  in  the  form  of  a  de- 
posit, whilst  the  latter  being  insoluble  in  alkaline  solutions 
are  deposited  whenever  the  urine  becomes  alkaline. 

To  determine  separately  the  respective  quantities  of 
the  alkaline  and  earthy  phosphates,  we  have  first  to 
determine  the  whole  amount  of  j)hosphoric  acid  com- 
bined with  both  kinds  of  bases,  which  is  done  by  the  pro- 
cess described  in  Aiypendix  I.,  No.  3.  Having  determined 
the  total  amount  of  phosphoric  acid,  the  earthy  phos- 
phates are  removed  from  another  sample  of  the  urine  by 


PHOSPHATES.  91 

precipitation  with  liquor  ammonia,  and  the  amount  of 
phosphoric  acid  in  the  filtrate  determined  by  the  same 
process  as  before,  the  result  gives  the  amount  of  alka- 
line phosphates  which  remained  in  the  filtrate  after 
the  removal  of  the  earthy  phosphates  by  precipitation. 
Then  by  deducting  the  amount  of  phosphoric  acid  in  com- 
bination with  the  alkaline  bases  from  that  of  the  total  phos- 
phoric acid,  we  learn  the  amount  of  the  earthy  phos^^hates 
present.  Thus^  for  example ^  the  total  phosphoric  acid  in 
the  twenty-four  hours'  uiine  amounts  to  3*1  grms.,  and 
that  in  combination  with  the  alkaline  bases  is  1'9  grms., 
then  the  pho^horic  acid  in  combination  with  lime  and 
magnesia  amounts  to  1*2  grms.  These  figures  represent 
approximately  the  normal  excretion  of  phosphoric  acid  in 
the  twenty-four  hours'  urine,  audits  distribution  among  the 
alkaline  and  earthy  bases. 

a.  The  Alkaline  Phosphates  exist  in  the  blood  in 
the  form  of  neutral  sodiam  and  potassium  phosphates 
(hydrogen  di-sodium  phosphate,  HNa2P04),  biit  appear  in 
the  urine  as  acid  sodium  and  potassium  phosphates  (di- 
hydrogen  sodium  phosphate,  HgNaPOi),  and  thus  cause 
the  acid  reaction  of  that  secretion.  This  change  of  the 
neutral  into  the  acid  salt  is  caused  by  a  decomposi- 
tion effected  by  the  act  of  secretion  in  which  the  bicar- 
bonates  and  neutral  phosphates  in  the  blood,  are  changed 
into  carbonates  and  acid  phosphates  respectively.  The 
acid  salt  in  obedience  to  the  law  of  diffusion  passing  out 
into  the  urine,  whilst  the  carbonate  remains  in  the  cir- 
culation as  follows : — 

Bicarbonate  Neutral  Phosphate  Carbonate  Acid  Phosphate 

HNaCOs    +      HNa^PO,      =     Na^COs    +    H,NaPO, 

This  explanation  of  the  seeming  paradox  of  how  an 
acid  secretion  can  be  formed  from  the  alkaline  blood  was 


92 


DISEASES    OF    THE    KIDNEY. 


first  suggested,  and  proved  to  be  experimentally  possible, 
in  a  communication  addressed  to  the  Lancet,  July,  1874. 

The  presence  of  the  alkaline  phosphates  can  be  detected 
by  the  following  tests.  (1)  A  yeUow  precipitate  with  silver 
nitrate  soluble  in  excess  of  ammonia  or  nitric  acid ; 
(2)  a  yellow  precipitate  with  nitric  acid  solution  of  am- 
monium molybdate. 

The  clinical  significance  of  the  alkaline  phosphates  has 
been  little  studied.  Under  normal  conditions  they  appear 
as  acid  salts  in  the  urine,  and  give  that  fluid  its  acid  reac- 
tion. Should  they  not  be  converted  into  acid  salts  in  their 
passage  through  the  kidney  they  may  appear  as  neutral 
phosphates,  in  which  case  the  urine  will  be  neutral  or 
alkaline,  though  when  this  is  the  case  the  alkaline  car- 
bonates are  also  usually  present  in  excess  since  these 
urines  invariably  effervesce  on  the  addition  of  dUute  acid. 
When  excreted  in  excess,  which  is  the  case  when  much 
animal  food  is  taken,  when  there  is  marked  disintegration 
of  the  nervous  system,  especially  as  Zuelzer  has  pointed  out, 
those  cases  attended  with  marked  depression,  and  during 
fevers,  the  increase  is  j)a-ri  passu  with  that  of  the  earthy 
phosphates,  so  that  there  is  really  practically  httle  to  be 
gained  by  making  a  separate  estimation  of  the  two,  the 
estimation  of  the  total  phosphoric  acid  being  a  sufficiently 
close  indication.  In  scurvy  I  have  observed  a  remark- 
able diminution  of  the  alkaline  phosphates  as  in  the  four 
cases  given  here  : — 


Cases. 


Alkaline     Phosphates 
1  week  after  admission. 


Alkaline     Phosphates 
after  2  weeks  of  lemon- 
juice- 


Case  1 
„  2 
»     3 

„    4 


0'76  grms. 
0-57      „ 
1-25      „ 

0  87      „ 


1'6  grms. 
1-6      „ 
1-7      „ 
13      ,. 


PHOSPHATES.  93 

In  these  cases  the  diet  was  the  same  throughout,  the 
only  difference  heing  the  administration  of  2ozs.  of  lemon- 
juice  daily,  which  could  not  possibly  account  for  the 
decided  increase  of  the  alkaline  phosphates.  It  therefore 
seems  to  me  probable,  that  the  alkaline  phosphates  are 
retained  in  the  system  in  scurvy,  to  supply  the  deficiency 
of  the  other  alkaline  salts,  the  carbonates  and  bicarbon- 
ates,  which  are  withdrawn  when  fresh  vegetables  are 
withheld,  (see  Clinical  Chemibtry,  p.  292). 

Dr.  Gee  (St.  Bartholomew's  Hospital  Reports,  vol.  viii.), 
has  pointed  out  the  remarkable  diminution  of  phosphoric 
acid,  even  to  complete  absence,  in  cases  of  ague. 

Schultze  [Zeit.f.  Biologie,  xix.,  p.  301),  has  remarked  a 
considerable  diminution  of  phosphoric  acid  in  the  urine 
after  the  administration  of  bromide  of  potassium, 

A  deficiency  of  the  alkaline  phosphates  is  often  noted 
in  the  urines  of  ill-nourished  and  strumous  children, 
which  deposit  a  considerable  quantity  of  uric  acid.  The 
alkaline  phosphates  are  also  considerably  diminished  in 
chronic  Bright's  disease. 

b.  The  Earthy  Phospihates. — The  phosphoric  acid  in  com- 
bination with  the  earthy  bases  in  the  urine  forms  three 
salts,  calcium  phosphate  (Ca3,2P04),  magnesium  phosphate 
(MgHPOijTHaO),  and  ammonium- magnesium  phosphate 
(NH4MgP04,6H20).  The  latter  however  only  being  formed 
as  the  result  of  disease  of  the  genito-urinary  passages. 

Calcium  Phosphate  is  deposited  from  the  urine  in  two 
forms,  most  commonly  as  amorphous  granules,  occasionally 
as  fine  acicular  or  stellar  crystals,  (fig.  9).  This  deposit  only 
occurs  when  the  urine  is  alkaline  or  is  rendered  so  arti- 
ficially ;  on  the  addition  of  acid  it  is  speedily  dissolved. 
No  special  clinical  distinction  can  be  made  between  the 
amorphous  and  crystalline  deposits,  except  that  the  former 
is  by  far  the  most  common.     The  fine  acicular  crystals 


94 


DISEASES    OF    THE    KIDNEY, 


may  be  mistaken  for  uric  acid  crystals,  in  all  cases  there- 
fore it  is  well  to  add  a  drop  of  dilute  acid  to  tlie  deposit 
under  the  microscope,  if  the  crystals  are  calcium  phos- 
phate they  will  dissolve,  if  uric  acid  they  will  not  dissolve. 
Occasionally  this  deposit  will  come  down  in  urines,  which 


Fig.  9. — Stellar  phosphates. 

are  slightly  acid,  on  boiling,  and  this  turbidity  is  likely  to 
be  mistaken  for  albumin,  only  the  latter  is  not  redissolved 
by  the  addition  of  acid.  The  cause  of  this  deposition  of 
calcium  phosphate  is  generally  assumed  to  be  the  driving 
off  of  free  carbonic  acid,  which  is  supposed  to  keep  the 
calcium  phosphate  in  solution,  by  boihng.  If  this  were 
BO  then  the  precipitate  should  be  permanent,  but  it  redis- 
solves  on  cooling.  Salowski  {Z eitschrift  fi'ir  Phys.  Chiniie, 
1883)  believes  the  precipitation  is  caused  by  the  decomposi- 
tion of  an  existing  combination  of  calcium  phosphate  and 
alkaline  phosphate.  Dr.  Smith  of  Dublin  {Brit.  Med.  Jour., 
1883,  vol.  ii.,p  68)  from  experiments  made  with  Dr.  Emerson 
Eeynolds,  believes  the  precij)itate  depends  on  a  nice  ad- 
justment in  the  proportions  and  basisity  of  the  phos- 
phatic  salts  existing  in  urine,  and  gives  the  following 
equation  to  explain  what  happens  when  heat  is  apphed : 

2(Ca,H2P208)  +  CaH,PA 
=  Ca3P208(insoluble)  -)-2CaH4P208(^soluble). 
On  cooling,  an  inverse  change  takes  place. 


PHOSPHATES.  95 

Magnesium  Phosphate  is  deposited  with  the  calcium 
phosphate,  and  for  all  practical  purposes  they  may  be  con- 
sidered together.  To  separate  the  two  if  necessary,  am- 
monium oxalate  is  added  to  the  urine  which  tlirows  down 
the  lime  as  calcium  oxalate,  this  is  removed  by  filtration, 
and  ammonia  is  added  to  the  filtrate  which  precipitates 
the  magnesia  as  ammonium-magnesium  phosphate. 

The  clinical  significance  of  deposits  of  calcium  and  mag- 
nesium phosphate  may  be  considered  with  reference  to 
deposits  occurring  simply  from  an  alkaline  condition  of 
the  urine  without  any  excessive  ehmination  of  the  earthy 
phosphates,  and  those  due  to  excessive  elimination. 

Deposit  of  earthy  phosphates  without  excessive  ehmina- 
tion. The  urine  is  alkaline  from  fixed  alkali,  and  is  turbid 
or  whey-like  from  the  deposited  phosphates;  or  if  the 
urins  is  clear  and  slightly  acid  when  passed,  it  becomes 
turbid  when  boiled.  The  alkalinity  in  these  cases,  since 
the  alkahne  phosphates  are  not  generally  increased,  is 
mainly  due  to  the  bicarbonates  of  potash  and  soda  being 
excreted  in  excess,  these  urines  consequently  effervesce  on 
the  addition  of  an  acid  (see  Phosphaturia). 

Excess  of  earthy  phosphates,  not  however  always  de- 
posited. In  these  cases  the  amount  of  earthy  phosphates  is 
immensely  increased,  as  is  also  the  alkaline.  The  urine 
is  generally  alkaline,  and  when  this  is  the  case  the  earthy 
phosphates  are  thrown  down  as  a  mealy  dense  precipitate. 
This  deposition  often  occurs  in  the  bladder,  the  urine  first 
passed  being  clear,  the  last  portion  being  thick  and  passed 
often  with  great  straining  and  irritation.  Frequently,  how- 
ever, the  urine  is  not  alkaline  but  acid,  so  that  no  deposit 
occurs,  and  till  a  quantitative  estimation  is  made  it  is  im- 
possible to  tell  that  phosphoric  acid  is  being  eliminated  in 
excess.  In  other  cases  the  two  conditions  alternate,  an 
alkaline  reaction  with  deposits  of  phosphate  alternating 


96  DISEASES    OF    THE    KIDNEY. 

with  highly  acid  urine  depositing  uric  acid  and  urates  (see 
Polyuria  and  Phosphaturia). 

c.  Ammonium  Magnesium  Phosphate,  (NH4MgP04,6H20), 
is  formed  only  when  the  urine  becomes  alkaline  from 
volatile  alkali  (ammonia).  This  occurs  whenever  fermen- 
tation takes  place  in  the  urinary  passages  (see  page  64). 
This   salt  is   also   called  triple   phosphate,    and  is    met 


Fig.  10. — Triple  phosphates. 

with  in  different  forms,  the  most  characteristic  being  as 
triangular  prisms  (fig.  10),  less  frequently  as  feathery 
crystals.  The  crystals  are  soluble  in  dilute  acids.  Although 
usually  found  in  alkaline,  still  they  are  sometimes  met 
with  in  slightly  acid,  urine.  In  these  cases  it  is  probable 
that  the  urine  contains  a  salt  which  reddens  litmus  paper, 
but  which  is  not  a  free  acid.  A  mixture  of  calcium  phos- 
phate and  ammonium  magnesium  phosphate  fuses  under  the 
blow-pipe  into  an  enamel-like  crust.  The  pathological 
conditions  that  lead  to  the  formation  of  triple  phosphate  in 
urine  wih  be  found  described  in  the  section  on  stone  and 
gravel  (see  Calculus). 

19.  Unoxidised  Phosphorus.— Although  the  greater 
part  of  the  phosphorus  eliminated  from  the  body  passes  out 
in  the  oxidised  form  as  phosphoric  acid  in  combination  with 
bases,  still  a  small  portion,  almost  imperceptible  under 
normal  conditions,  but  increased  in  some  pathological 
states,  or  by  the  influence  of  certain  kinds  of  food,  passes 


UNOXIDISED    PHOSPHORUS.  97 

off  by  the  urine  tmoxidised  in  combination  with  organic 
substances,  in  the  form  of  lecithin,  protagon  or  glycerin- 
phosphoric  acid.  This  can  be  indu-ectly  estimated  by 
boiling  the  urine  for  some  time  with  strong  nitric  acid, 
which  liberates  the  phosphorus  from  its  organic  combina- 
tion, and  oxidises  it  into  this  form  of  phosphoric  acid,  and 
the  amount  of  phosphoric  acid  determined  by  the  usual 
method  (Appendix  I.,  No.  3).  Now  if  the  amount  of 
phosphoric  acid  has  been  previously  determined  in  an 
equal  sample  of  the  same  urine,  before  boiling  with  nitric 
acid,  the  difference  between  the  two  quantities  will  give 
the  amount  of  phosphoric  acid  derived  by  the  oxidation  of 
organic  phosphorus.  Thus  100  c.c.  of  urine  before  boiling 
with  nitric  acid  gives  0-172  grms.,  and  after  boiling,  0-183 
grms.,  then  the  amount  of  phosphoric  acid  derived  from  the 
organic  compounds  weighs  -Oil  grms.  Sotnischewsky 
{Zdtschr.f.  Phys.  Chemie,  Bd.  4,  §  215)  gives  a  more  exact 
process,  as  follows.  The  twenty-four  hours'  urine  is  ren- 
dered alkaline  with  milk  of  lime,  and  precipitated  with  cal- 
cium chloride.  Filter,  evaporate  filtrate,  and  extract  resi- 
due with  alcohol.  The  residue  not  dissolved  with  alcohol 
is  dissolved  in  water,  to  both  solutions  add  a  solution  of 
ammonia  and  magnesia,  and  allow  the  mixture  to  stand 
twenty-four  hours  in  order  to  remove  traces  of  the  inor- 
ganic phosphoric  acid  that  may  still  be  present.  Filter, 
render  the  filtrate  strongly  acid  with  sulphuric  acid,  and 
boil  for  some  time,  in  order  to  separate  the  glycerin- 
phosphoric  acid.  After  coohng,  solution  of  ammonia  is  to 
be  added,  when  on  standing  crystals  of  ammonium-mag- 
nesium phosphate  are  deposited,  these  are  to  be  collected 
and  weighed,  from  whence  the  amount  of  phos^jhoric  acid 
derived  from  the  organic  compounds  can  be  deduced. 
Should  it  be  required  to  estimate  the  organic  compound  as 
lecithin,  the  crystals  of  ammonium-magnesium  phosphate 

H 


98  DISEASES    OF    THE    KIDNEY. 

must  be  weiglied  in  a  platinum  capsule,  whose  weight  is 
known,  and  then  brought  to  a  white  heat,  till  a  glassy 
mass  is  left  at  the  bottom  of  the  capsule.  This  is  mag- 
nesium pyrophosphate,  which  must  be  carefully  weighed  ; 
now  100  parts  of  pyrophosphate  are  equivalent  to  764'8 
parts  of  lecithin.  If  therefore  the  pyrophosphate  amounts 
to  0'026  grms.,  then  the  amount  of  lecithin  in  the  twenty- 
four  hours'  urine  will  be  1*9764  grms. 

Zuelzer  {op.  cit.,  pp.  15-24),  who  has  paid  much  atten- 
tion to  the  clinical  and  pathological  significance  of  the 
unoxidised  phosphorus  in  urine,  observes  that  the  amount 
in  normal  urines  is  quite  insignificant,  it  is  increased 
however,  whenever  the  animal  is  fed  on  such  substances 
as  brain,  glycerine,  butter,  etc.  Keeping  the  urine 
diminishes  the  amount,  owing  no  doubt  to  the  oxidation 
that  occurs.  The  diseases  in  which  it  has  been  found  in 
the  largest  amount,  have  been  chyluria,  pernicious  anae- 
mia, dementia,  lesions  of  brain  substance,  diabetes  melli- 
tus,  and  after  the  administration  of  chloroform.  L. 
Egmonnet  (J.  Pharm.  §  7,  p.  134),  has  found  a  notable 
amount  of  glycerin-phosphoric  acid  in  the  urine  of  phthisi- 
cal patients,  and  that  the  livers  of  these  patients  contain 
often  as  much  as  3 '38  per  cent,  of  lecithin.  The  same 
observer  has  also  made  an  important  observation  on  the 
excretion  of  the  hypophosphites  by  the  urine.  Having 
injected  sodium  hypophosphite  into  the  veins  of  a  dog,  it 
was  found  that  the  dose  was  eliminated  in  twenty-four 
hom's ;  part  as  phosphate,  and  the  remainder  as  hypo- 
phosphite.  The  amount  of  phosphate  ehminated,  however, 
appears  to  increase  in  greater  ratio  to  that  of  the  hypo- 
phosphite,  in  proportion  to  the  increase  of  the  dose.  It  need 
hardly  be  said  that  the  subject  is  one  of  considerable 
clinical  and  pathological  importance,  and  the  estimation 
of  the  amount  of  lecithin  daily  passed  out  of  the  body  by 


SULPHATES.  99 

the  urine,  ought  to  afford  a  useful  indication  of  the  extent 
as  well  as  the  intensity  of  nerve  disintegration  in  certain 
morhid  conditions  of  the  nervous  system. 

20.  Sulphates. — Sulphuric  acid  in  the  body  combines 
chiefly  with  the  alkaline  oxides  of  potassium  and  sodium, 
and  to  a  small  extent  with  lime.  They  are  extremely  solu- 
ble, so  that  the  sulphates  never  form  a  urinary  deposit. 
Sulphuric  acid  is  detected  by  means  of  barium  chloride,  to 
which  a  few  drops  of  hydrochloric  acid  should  be  added  to 
insure  complete  precipitation  of  the  sulphate.  This  pro- 
cess is  used  for  their  quantitative  estimation,  (Appendix  I., 
No.  4).  The  amount  of  sulphuric  acid  passing  off  from 
the  body  by  the  urine  in  the  twenty- four  hours,  is  about 
2'5  grms.  to  3  grms.  The  quantity  is  said  to  be  in- 
creased by  a  meat  diet,  and  decreased  by  a  vegetable  one, 
but  this  is  misleading,  since  many  vegetables  in  common 
daily  use,  as  cabbages,  beans,  peas,  etc.,  contain  much 
sulphur,  and  onions  allyl  sulphide,  and  mustard  aUyl 
sulpho- cyanide.  An  habitually  large  excretion  of  sul- 
phuric acid  with  excess  of  urea  indicates,  however,  a  pre- 
ponderance of  animal  food.  In  disease,  their  excretion  is 
increased  in  fevers,  in  acute  rheumatism,  meningitis  and 
pneumonia.  When  carboUc  acid  has  been  taken  in  large 
quantities,  the  sulphates  may  entirely  disappear  from  the 
urine,  being  converted  into  sulpho-carbolates. 

21.  Unoxidised  Sulphur. — Only  a  small  portion  of  the 
sulphur  introduced  into  the  body  with  the  food  appears  in 
the  urine.  A  considerable  portion  passes  off  by  the 
bowels,  a  part  of  which  consists  of  the  sulphur  of  undi- 
gested food,  a  part  of  the  sulphur  of  the  altered  bile  acid 
(tauro-choHc),  one-fifteenth  of  which  Bidder  and  Schmidt 
have  shown  to  be  thus  disposed  of.  The  remaining  portion  of 
this  acid  is  reabsorbed  from  the  intestine,  and  the  greater 
part    undergoes    further    change  in  the    economy,   but 

H  2 


100  DISEASES    OF    THE    KIDNEY. 

its  ultimate  fate  is  at  present  unknown.  Whilst  a  very 
small  portion  passes  off  by  the  urine,  and  can  be  recog- 
nised even  in  health  (Naunym  and  Dragendorff)  by  the 
ordinary  tests  for  bile  acids,  and  lastly  a  small  portion  of 
this  acid  is  partially  oxidised,  and  furnishes  the  sulphur 
product  originally  discovered  by  Eonalds,  and  which  in 
minute  quantities  always  exists  in  the  urine.  A  portion 
of  the  sulphur  introduced  into  the  body  is  also  eliminated 
by  the  skin,  in  the  perspiration,  hair,  nails,  and  cuticle. 
The  amount  of  unoxidised  sulphur  that  passes  off  into  the 
urine  in.  health  amounts  to  0*4  grms.  To  estimate  it  we 
first  ascertain  the  amount  of  sulphuric  acid  present  as 
sulphate,  by  means  of  barium  chloride,  [Appendix  I.,  pro- 
cess 4) ,  and  eva]3orate  an  equal  portion  of  the  same  urine 
to  dryness,  and  deflagrate  it  with  potassium  nitrate.  By 
this  means  the  unoxidised  sulphur  is  converted  into  sul- 
phuric acid.  This  is  estimated  by  barium  chloride,  the 
amount  of  sulphuric  acid  obtained  being  of  course  greater 
than  in  the  first  instance,  the  difference  between  the  two 
amounts,  being  the  amount  of  unoxidised  sulphur  present. 
The  clinical  and  pathological  significance  of  an  increase 
in  the  amount  of  this  unoxidised  sulphur  in  the  urine  has 
not  been  determined.  It  is  observed  in  many  instances  of 
disturbed  hepatic  function,  as  well  as  in  organic  disease  of 
the  Hver,  and  of  course  is  always  noted  in  cystinuria. 

22.  Chlorides. — Hydrochloric  acid  in  the  urine  is  chiefly 
found  in  combination  with  sodium,  and  to  a  less  extent 
with  potassium.  The  amount  varies  considerably  from  5 
to  8  grms.  according  to  the  amount  of  salt  ingested. 
About  one-fifth  of  the  chloride  of  sodium  ingested  however 
appears  in  the  urine  as  chloride  of  potassium,  being 
decomposed  by  acid-potassium  phosphate  into  potassium 
chloride  and  acid- sodium  phosphate.  The  chlorides  being 
soluble,   they  never  appear  in  the  urine  as  a  deposit. 


ABNORMAL    CONSTITUENTS.  101 

Evaporated  to  dryness,  however,  octohedral  crystals  and 
rhombic  plates  of  urea  and  sodium  chloride  will  be  formed. 
Solution  of  silver  nitrate  throws  down  the  chlorides  as  a 
white  curdy  precipitate  insoluble  in  excess  of  nitric  acid, 
but  soluble  in  excess  of  ammonia.  In  applying  this  test  to 
urine,  it  is  necessary  first  to  add  a  few  drops  of  nitric  acid 
to  prevent  the  deposition  of  the  phosphates.  Two  methods 
are  employed  for  the  quantitative  determination  {Appeyidix 
I.,  No.  5,)  that  of  Liebig  by  means  of  a  mercuric  nitrate 
solution,  or  that  of  Mohr  with  silver  nitrate. 

The  chlorides  are  diminished  in  all  acute  febrile 
diseases.  In  pneumonia  the  diminution  commences  at 
the  stage  of  hepatization,  they  reappear  gradually  as 
resolution  sets  in.  Partes  says  that  sometimes  they  may 
be  retained  some  days,  and  that  then  they  are  poured  out 
in  such  quantities  as  to  raise  the  specific  gravity  of  the 
urine,  although  the  water  is  increasing  and  the  other  solids 
decreasing.  In  acute  rheumatism  with  effusion  into  the 
joints,  and  in  exudative  pleurisy,  a  considerable  decrease 
is  likewise  noted.  The  decrease  in  these  diseases  is  mainly 
accounted  for  by  the  fact  that  the  exudation  material 
poured  out  is  particularly  rich  in  chlorides.  In  ague 
during  the  cold  and  hot  stages,  the  excretion  of  chlorides 
is  greatly  increased. 


Abnoemal  Constituents. 

23.  Serum  Albumin. — Serum  albumin  coagulates  at  a 
temperature  of  73°  to  75°  C,  this  is  its  chief  distinguishing 
feature  from  all  other  forms  or  modifications  of  albumin, 
except  serum  globulin.  The  heat  test  therefore  can  be 
alone  rehed  upon  to  prove  the  presence  of  serum  albumin 
and  serum  globulin,  the  most  important  forms  of  albu- 


102  DISEASES    OF    THE    KIDNEY. 

min  clinically.  Other  reagents  precipitate  it  from  urine, 
of  which  those  most  frequently  in  use  are  nitric  acid,  picric 
acid,  potassio-mercuric  iodide,  acid  solution  of  common 
salt,  sodium  tungstate,  and  potassium  ferrocyanide  with 
acetic  acid,  but  as  these  also  give  reactions  with  other 
forms  and  modifications  of  proteid  bodies,  they  are  not  to 
be  reUed  on  except  as  showing  the  presence  of  a  proteid 
substance. 

In  testing  for  albumin,  the  following  procedure  should 
be  adopted.  The  urine  should  be  rendered  perfectly  clear. 
If  alkaline  and  turbid  from  phosphates,  a  few  drops  of 
dilute  acetic  acid  are  to  be  added  till  the  urine  acquires  a 
shght  acid  reaction  when  it  becomes  clear,  but  not  other- 
wise.  If  thick  from  deposited  urates,  the  urine  must  be 
warmed  to  a  blood  heat  (40°  C) ,  when  the  deposit  dissolves. 
If  cloudy  from  mucus,  it  must  be  filtered. 

(1)  Heat  Test. — A  test-tube  is  then  filled  with  the  urine, 
and  the  upper-third  heated  over  a  spirit  lamp,  and  the 
temperature  gradually  raised  to  the  boiling  point.  Coagu- 
lation occurs  just  before  ebullition,  and  varies  from  a 
mere  haze  to  a  dense  white  cloud,  made  up  of  masses 
of  coagulated  albumin,  which  does  not  redissolve  on  the 
addition  of  dilute  acetic  acid.  By  holding  the  test- 
tube  up  to  the  hght  against  the  coat  sleeve,  the  slightest 
haze  in  the  heated  portion  may  be  distinguished  and 
contrasted  with  the  perfectly  clear  fluid  in  the  lower 
and  cold  portion  of  the  test-tube.  In  employing  this 
test  we  must  guard  against  three  fallacies,  a.  The  cloud 
may  be  mistaken  for  phosphates,  it  can  however  be  readily 
distinguished  by  the  addition  of  dilute  acid,  the  phosphates 
at  once  being  redissolved,  whilst  albumin  is  not.  b.  If  the 
urine  is  highly  alkaline,  the  serum  albumin  may  be  converted 
into  alkah  albumin  (casein) ,  which  is  not  coagulated  by  heat, 
this  mistake  however  is  not  hkely  to  arise  if  the  precaution  of 


ALBUBIIN.  103 

rendering  the  urine  acid,  as  j)reviously  directed,  is  attended 
to.  If  however  it  has  been  neglected,  the  addition  of  a 
drop  or  so  of  dilute  acid,  or  one  of  Dr.  OHver's  citric  acid 
papers  will  convert  the  alkali  albumin  into  serum  albumin, 
and  the  required  coagulation  will  take  place,  c.  If  the 
urine  be  too  highly  acid,  the  albumin  will  be  converted 
into  acid  albumin  (syntonin)  which  also  is  not  coagulated 
by  heat,  in  this  case  a  drop  of  liquor  potassaa,  or  one  of 
Dr.  Oliver's  sodium  carbonate  test  papers,  added  to  the 
urine,  wiU  convert  the  acid  albumin  into  serum  albumin, 
and  coagulation  wiU  occur.  It  is  rare,  however,  for  urine 
to  be  passed  so  highly  acid  as  to  change  the  albumin  into 
acid  albumin,  when  it  occurs,  it  is  generally  from  using  a 
test-tube  which  has  been  imperfectly  cleaned,  and  contains 
a  few  drops  of  acid  on  its  sides  and  bottom. 

The  heat  test  thus  appHed  affords  sufficient  indications 
for  cHnical  purposes,  and  though  the  more  delicate 
reagents  are  useful  in  determining  minute  quantities  of 
albumin,  especially  as  regards  the  ultimate  clearing  up  of 
an  attack  of  albuminuria,  they  should  never  be  entirely 
relied  on,  partly  because  they  sometimes  precipitate  other 
bodies  such  as  urates,  alkaloids,  peptone  mucin,  &c.,  and 
partly  because  in  themselves  they  do  not  discriminate  be- 
tween the  modifications  and  other  forms  of  albumin.  It 
matters  little  however  which  reagent  is  selected  so  long 
as  heat  is  one  of  the  tests  employed.  The  other  reagents 
besides  heat  commonly  in  use  for  clinical  purposes  are  : — 
(2)  Kitric  Acid  [Heller' s  Test). — About  thirty  drops  of  strong 
nitric  acid  are  placed  in  the  bottom  of  a  test-tube,  and 
then  an  equal  quantity  of  urine  is  floated  gently  over  the 
surface  of  the  acid,  at  the  line  of  junction,  a  zone  of  coagu- 
lated albumin  is  developed,  and  which  does  not  disappear 
when  heated.  Nitric  acid  gives  this  reaction  as  well  with 
alkali  and  acid  albumin  as  with  serum  albumin,  but  not 


104  DISEASES    OF    THE    KIDNEY. 

with  true  peptones.  A  fallacy  may  arise  by  the  appear- 
ance of  a  zone  of  hydrated  uric  acid  in  highly  acid  urines, 
or  amorphous  urates  in  neutral  urines,  being  developed  at 
the  hne  of  junction,  this  however  disappears  when  heat  is 
applied.  Crystals  of  urea  nitrate  may  be  formed  on  the 
addition  of  nitric  acid  to  concentrated  urines,  but  they  too 
dissolve  on  the  application  of  heat. 

(3)  Potassio-Mercuric  Iodide  (Tauret's  Test)  accord- 
ing to  Dr.  Oliver's  researches  is  the  most  sensitive  test 
known,  and  he  considers  that  citric  acid  adds  to  its  sen- 
sitiveness. It  precipitates  alkali  and  acid  albumin,  as 
well  as  serum  albumin,  also  peptones,  alkaloids  and  urates. 
The  application  of  the  heat  test  is  therefore  necessary  to 
discriminate  between  these,  (a)  The  precipitate  redis- 
solves  when  heated,  which  shows  it  to  consist  of  either  pep- 
tones, alkaloids,  or  urates,  fb)  A  fresh  sample  coagula- 
ting by  heat  shows  it  to  be  serum  albumin,  and  not  acid  or 
alkali  albumin. 

(4)  Picric  Acid  (Johnson's  Test)  is  also  a  very  deHcate 
reagent  for  proteid  substances,  audits  use  has  been  strongly 
advocated  by  Dr.  George  Johnson.  It  precipitates  both 
serum,  alkali  and  acid  albumin,  peptones,  urates,  alka- 
loids and  oleo -resins,  the  four  latter,  however,  are  redis- 
solved  by  heat.  Dr.  Oliver  has  shown  that  the  addition 
of  citric  acid  also  renders  its  action  more  sensitive. 

Other  reagents  are  meta-phosphoric  acid,  sodium  tung- 
state,  potassium  ferrocyanide  with  acetic  or  citric  acid, 
and  the  brine  solution  of  Dr.  Eoberts,  consisting  of  a 
saturated  solution  of  common  salt  with  ten  per  cent,  of 
hydrochloric  acid.  As  they  possess  no  advantages  over  the 
above,  they  need  not  be  dwelt  upon  at  length.  The  mer- 
curic and  picric  acid  and  other  tests  are  now  conveniently 
applied  by  means  of  Dr.  Oliver's  prepared  papers,  an  in- 
vention which  has  done  much  to  facilitate  the  testing  of 
urine  at  the  bedside. 


ALBUMIN.  105 

Serum  albumin  gives  to  its  solutions  a  specific  rotatory 
power  for  light  of — 56°,  the  polariscope  has  therefore  been 
proposed  for  its  detection,  but  there  are  many  difficulties  in 
the  way  of  making  a  calculation  in  the  case  of  urine,  and 
it  could  only  be  available  in  the  hands  of  an  expert. 

The  procedure  for  making  an  exact  quantitative  esti- 
mation of  albumin  is  described  in  Appendix  I.,  No.  6.  In 
no  case  ought  the  rough  clinical  method  of  judging  the 
amount  from  the  depth  of  the  deposit  at  the  bottom  of  a 
test-tube  in  relation  to  the  amount  of  urine  to  be  relied  on  ; 
for  independently  of  the  fallacy  arising  from  an  individual 
sample  being  of  a  higher  or  lower  specific  gravity  than 
another,  it  must  be  remembered  that  urates  or  phosphates, 
together  with  mucus,  casts,  granular  debris,  etc.,  are  all 
liable  to  collect  together  at  the  bottom  of  the  tube,  and  so 
swell  the  bulk  of  the  deposited  albumin. 

The  best  ready  method  for  determining  approximately 
the  amount  of  albumin  present  in  urine  is  Dr.  Oliver's,  in 
which  all  the  albumin  in  a  measured  portion  of  the  urine 
is  precipitated  by  a  test-paper,  and  then  the  opacity  is 
compared  with  a  prepared  standard  of  opacity,  which  is 
best  furnished  by  a  piece  of  ground-glass.  The  procedure  is 
as  follows : — The  test-tube,  which  is  flattened  and  graduated 
into  twenty  divisions  of  ten  minims  so  as  to  hold  200 
nunims,  has  twenty  minims  of  urine  placed  in  it  and  then  a 
test-paper  (potassio -mercuric  iodide  is  the  most  suitable),  is 
dropped  in.  The  contents  of  the  tube  are  well  shaken  and 
the  resulting  opacity  observed.  This  is  done  by  placing  a 
card,  on  which  lines  of  various  degrees  of  thickness  are 
printed,  behind  the  test-tube.  If  the  opacity  completely 
obscures  the  lines,  we  may  dilute  with  water  pretty  freely 
from  a  graduated  pipette,  at  first  say  up  to  six  measures 
or  40  minims  of  water,  shake  gently,  taking  care  not  to 
froth  the  mixture.    The  opacity  is  again  observed  by  means 


106  DISEASES    OF    THE    KIDNEY. 

of  the  printed  card,  if  the  opacity  is  still  greater  than 
that  given  hy  opaque  glass,  the  standard  of  compari- 
son, then  water  must  be  added  one  division  (10  minims) 
at  a  time  till  the  opacity  of  the  urine  in  the  test-tube 
exactly  corresponds  with  the  opacity  of  the  standard  of 
the  ground-glass,  and  which  is  readily  observed  by  means 
of  the  hues  on  the  printed  card.  The  calculation  is  made 
by  multiplying  together  the  known  value  of  the  precipitant^ 
according  to  the  test-paper  used,  and  the  number  of  times 
the  volume  of  the  urine  has  been  increased  by  dilution  ; 
thus,  in  the  case  of  the  mercuric  paper,  the  standard  of  opa- 
city is  one-tenth  2>er  cent.,  if  therefore  it  is  necessary  to  dilute 

the  20  minims  of  urine  to  180  minims  then =•& 

20 

per  cent,  of  albumin.  K  the  albumin  should  be  so  abundant 
that  the  standard  of  opacity  is  not  reached  till  over  200 
minims  of  water  have  been  added,  the  test  should  be  again- 
repeated,  but  this  time  only  adding  10  minims  of  urine 
instead  of  twenty,  then  if  the  dilution  is  carried  to  140 

minims,   =  1*4  per  cent,  of  albumin.     When  the 

10  ^ 

lines  on  the  card  can  be  read  at  once  without  any  dilution 
of  water,  the  quantity  of  albumin  is  below  one-tenth  per  cent. 
This  method  of  Dr.  Ohver's  is  one  of  the  most  valu- 
able additions  to  practical  urinary  work  that  has  been  made 
for  sometime  past,  for  without  going  so  far  as  to  say  that 
it  gives  absolutely  correct  results  as  to  weight,  it  un- 
doubtedly furnishes  us  with  a  very  fair  approximate  idea  as 
to  the  variations  in  the  amount  of  albumin  taking  place 
from  day  to  day  in  the  progress  of  a  case.  No  positive 
deduction  ought  to  be  made,  however,  from  either  the 
quahtative  or  quantitative  determination  of  albumin  in  a 
single  sam^jle  of  urine,  the  quahtative  examination  should, 
be  •  extended  to  as  many  samples  as  possible,  especially 


PARAGLOBULIN.  107 

those  passed  on  first  rising  in  the  morning,  after  food,  and 
■  after  exercise  has  been  taken,  whilst  a  quantitative  deter- 
mination of  the  twenty-four  hours'  urine  should  be  made  at 
least  once  a  week. 

24.  Paraglobulin. — Paraglobulin  or  serum  globulin  is- 
generally  found  in  urine,  associated  with  serum  albumin 
from  which  it  may  be  separated  by  the  addition  of  mag- 
nesium sulphate  to  complete  saturation.  The  precipitate 
is  filtered  off,  and  carefully  washed  in  hot  water  (75°  C) 
till  all  traces  of  sulphate  are  removed ;  the  filtrate  con- 
tains the  serum  albumin.  Paraglobului  can  also  be  obtained 
by  diluting  the  urine  to  twice  its  bulk  with  distilled  water 
and  passing  a  cm-rent  of  carbonic  acid  through  the  mix- 
ture ;  should  the  urine  be  neutral  or  alkaline  it  will  be 
necessary  to  render  it  slightly  acid,  by  means  of  a  few 
drops  of  dilute  acetic  acid.  Until  the  researches  of 
Hammarsten  it  was  supposed  that  paraglobulin  was  pre- 
sent in  only  small  quantities  as  compared  with  serum 
albumin,  and  its  presence  in  the  urine  was  entirely  over- 
looked. It  is  now  shown  that  in  blood  the  proportion  of 
serum  globulin  to  serum  albumin  is  as  1  to  1*5,  and  in  the 
urine  it  is  sometimes  met  with  in  considerable  excess  of 
the  serum  albumin,  this  no  doubt  can  be  accounted  for  by 
the  fact  that  it  diffuses  more  readily  through  animal 
membranes  than  serum  albumin.  In  rare  cases,  which 
however  may  become  more  numerous  now  we  are  taught 
to  look  for  it,  paraglobulin  may  appear  without  being 
associated  with  serum  albumin.  I  have  seen  one  such 
case  whose  "life"  was  declined  for  albuminuria  and  whose 
urine  when  first  examined  contained  an  abundance  of 
both  albumins,  but  on  a  subsequent  examination  only  gave 
a  trace  of  paraglobulin.  As  a  rule,  however,  the  two  al- 
bumins are  always  associated ;  the  paraglobulin  has  been 
found  in  excess  in  the  following  class  of  cases,      (a)   In 


108  DISEASES    OF    THE    KIDNEY. 

the  intense  hyperemia  following  cantharides  poisoning, 
etc.  (b)  In  long  standing  cases  of  chronic  nephritis 
complicated  with  lardaceous  degeneration.  (c)  In  the 
early  stage  of  scarlet  fever  ne]Dhritis,  especially  in  children. 
(d)  In  functional  albuminuria  associated  with  marked 
disturbance  of  the  digestive  organs. 

25.  Modified  Albumins. — Acid  albumin  or  syntonin, 
and  alkaU  albumin  or  casein,  are  sometimes  observed  in  the 
urine,  when  that  fluid  is  either  highly  acid  or  alkaline. 
They  are  not  separated  from  the  blood  in  this  form,  but 
are  produced  by  the  action  of  the  acid  or  alkah  respectively 
of  the  urine,  or  in  dirty  test-tubes,  on  the  ordinary  albumin. 
As  they  give  no  reaction  with  heat,  they  may  be  over- 
looked unless  they  are  reconverted  into  ordinary  albumin, 
by  adding  an  alkali  or  acid  respectively.  For  this  pur- 
pose in  the  case  of  acid  albumin,  the  urine  is  neutrahsed 
with  a  few  drops  of  sodium  carbonate  solution,  carefuUy 
avoiding  excess,  and  then  heated,  or  better  still  by  dropping 
one  of  Dr.  Ohver's  sodium  carbonate  test-papers  into  the  hot 
urine,  when  a  streak  of  albuminous  opacity  will  follow  the 
paper  as  it  sinks  to  the  bottom.  In  the  same  way  with 
alkali  albumin,  we  neutralise  with  dilute  acetic  acid  and 
then  heat,  or  droxo  a  citric  acid  test-paper  into  the  hot 
urine  in  the  test-tube. 

26.  Peptones. — Peptones,  or  peptone  Hke  bodies  are 
very  frequently  to  be  met  with  in  the  urine,  both  associated 
with  albuminuria  as  well  as  independent  of  it.  They 
give  no  precipitate  with  heat  or  nitric  acid,  but  do  so  with 
picric  acid,  and  with  potassio-mercuric  iodide,  the  precipi- 
tate being  soluble  when  heated.  Their  special  distinguish- 
ing tests  are : — 

(a)  Eosy-red  with  alkaline  solution  of  cupric  sulphate. 
This  is  an  extremely  dehcate  reaction,  and  to  obtain  it  satis- 
factorily, it  must  be  performed  in  the  manner  described, 


PEPTONES.  ,  109 

British  Medical  Journal,  vol.  i.,  p.  662, 1883;  viz.,  a  drachm 
of  FeHing's  solution  is  placed  in  the  bottom  of  a  test-tube, 
and  then  a  drachm  of  the  urine  is  to  be  gently  floated  on 
the  surface,  at  the  point  of  contact  a  zone  of  phosphates 
form,  wliilst  just  above  this,  if  peptones  are  present,  a 
delicate  rose-coloured  halo  will  float.  Should  the  pep- 
tones be  mixed  with  serum  albumin  the  halo  will  be  mauve,. 
if  only  albumin  is  present,  purple. 

(b)  Yellow  precipitate  with  acid  mercuric  nitrate 
(Millon's  reagent)  and  potassium  iodide  ;  this  test  has 
been  devised  by  Dr.  Archer  Eandolph  of  Philadelphia.  It 
is  based  on  the  fact  that  if  Millon's  reagent  be  added  to  an 
aqueous  solution  of  iodide  of  potassium,  a  red  precipitate 
of  mercuric  iodide  results,  if  however,  peptones  or  bile 
acids  are  present  the  precipitate  is  yellow.  To  5  c.c.  of 
urine,  which  must  be  cold  and  only  faintly  acid,  two  drops 
of  saturated  solution  of  iodide  of  potassium  are  added,  and 
then  three  or  four  drops  of  Millon's  reagent,  then  if  pep- 
tones or  bile  acids  are  present,  a  yellow  precipitate  falls, 
the  question  as  to  the  presence  of  bile  acids  is  settled  by 
applying  the  special  tests  for  them.  The  test  is  so  delicate 
that  it  has  been  able  to  detect  peptones  in  the  proportion 
of  1  to  17,000  of  water. 

fc)  A  bulky  flocculent  precipitate  with  phospho-tungstate 
of  soda,  this  test  is  much  used  in  Germany. 

The  process  for  the  separation  of  peptones  from  the 
urine  is  a  long  and  difficult  one,  and  as  it  would  serve 
little  practical  purpose  here,  it  is  described  in  full  in 
Clinical  Cheinistry,  p.  148. 

The  occurrence  of  peptones  in  the  urine,  except  as  a 
rare  event,  has  been  doubted  by  Dr.  G.  Johnson,  but  the 
evidence  both  in  this  country  and  on  the  continent  goes  to 
show  that  their  presence  is  far  from  being  exceptional. 
Thus  the  observations  of  Hoffmeister,  {Zeit.  f.   Physiul. 


110  DISEASES    OF    THE    KIDNEY. 

■Chimie,  bd.  iv.,  §  260,  and  bd.  v.,  §  73),  Maixner  {Prager 
Vierteljahrsschf.,  bd.  cxliv.,  §  75),  and  Jakscb  (Zeit.  f.  Klin. 
Medicin,  bd.  vi.,  413,  1883)  have  shown  that  the  occur- 
Tence  of  pe^Dtones  in  urine  is  far  from  uncommon,  for 
not  only  are  they  found  in  the  urines  of  persons  suffer- 
ing from  acute  septic  diseases,  as  typhus,  diphtheria,  ter- 
tiary syphiHs,  small-pox,  cerebro- spinal  meningitis,  etc., 
l)ut  they  appear  also  when  pus  or  inflammatory  exudations 
are  absorbed  in  any  part  of  the  body.  Thus  Jaksch  has 
found  peptones  in  urine  in  croupous  pneumonia,  twenty- 
four  times  out  of  twenty -nine  cases  ;  in  four  cases  out  of 
five  of  pleuritic  effusion ;  and  twelve  cases  out  of  twelve 
cases  of  acute  rheumatic  effusion.  But  not  only  do  pep- 
tones appear  after  the  reabsorption  of  inflammatory  exu- 
dations in  the  blood,  but  their  characteristic  reactions 
develope  in  urine  whenever  young  cell  forms  are  formed 
in  excess  along  any  portion  of  the  genito-urinary  tract,  so 
that  peptonuria  occurs  on  very  slight  irritation  of  the 
urinary  mucous  surface. 

Occasionally  they  are  found  associated  with  temporary 
or  intermittent  albuminuria,  of  these  I  have  met  with  two 
instances  in  which  the  albumin  would  be  present  in  one 
sample,  and  absent  in  another,  and  I  am  inclined  to  believe 
in  these  cases  the  albuminuria  and  peptonuria,  were  depen- 
dent on  some  functional  derangement  of  digestion.  In  two 
other  cases,  peptones  were  present  without  any  albumin 
being  detected,  there  was  no  evidence  of  purulent  re- 
absorption  nor  of  pus  in  the  urine,  both  cases  pre- 
sented a  debilitated  appearance,  so  that  at  first  chronic 
Bright's  disease  was  suspected ;  my  friend  Dr.  Sansom  has 
informed  me  he  has  met  with  a  similar  case.  Again,  pep- 
tonuria may  result  from  decomposition  of  albumin  taking 
place  in  the  urinary  passages,  without  the  peptone  being 
derived  from  the  circulation,   since  any  albuminous  sub- 


HEMI-ALBUMOSE.  Ill 

stance  may  be  converted  into  peptone  by  prolonged  contact 
with  animal  or  even  vegetable  tissues.  Peptone  also  is 
formed  as  an  early  product  of  the  decomposition  of  proteid 
matter  by  bacteria.  It  will  thus  be  seen  that  any  given 
case  of  peptonuria  requires  extensive  clinical  investigation 
in  order  to  determine  the  origin  of  these  bodies. 

27.  Hemi-albumose  (Pro-peptone). — Pro-peptone  or 
para-peptone  is  one  of  the  bye-products  of  gastric  and  pan- 
creatic digestion.  According  to  recent  views,  the  initial  stage 
of  the  digestion  of  albumin  is  the  formation  of  anti-albumose 
and  hemi-albumose,  both  are  considered  as  para-peptones, 
the  former  resembling  syntonin,  the  latter  corresponding 
to  what  was  formerly  known  as  Meissner's  peptone.  It  is 
this  last  product  that  is  occasionally  met  with  in  urine, 
sometimes  associated  with  true  peptones,  occasionally  by 
itself.  Dr.  Bence  Jones  first  drew  attention  to  the  pres- 
ence of  this  proteid  substance  as  an  occasional  constituent 
of  urine,  having  found  it  in  a  case  of  osteo-malacia. 
Kiihne  [Zeitsft.  fur  Biologie,  xix.,  p.  209)  has  described 
a  case  of  osteo-malacia,  in  which  for  nearly  five  weeks  the 
patient  passed  urine  rich  in  hemi-albumose.  The  urine  de- 
posited an  abundant  sediment  consisting  chiefly  of  urates 
and  this  proteid  substance.  He  gives  the  following  di- 
rections for  its  separation.  The  proteids  were  separated 
by  precipitation  with  alcohol,  and  the  precipitate  washed 
and  dried  at  a  low  temperature  ;  the  dry  residue  was  only 
partially  soluble  in  water.  The  residue  insoluble  in  water 
was  again  extracted  with  water,  after  treatment  with  a  five 
per  cent,  solution  of  sodium  chloride.  The  aqueous  solution 
of  pure  hemi-albumose  obtained  by  these  means,  coagulates 
when  warmed,  if  the  solution  is  free  from  every  trace  of 
acid  or  alkali,  if  these  are  present  even  in  the  smallest 
degree  coagulation  is  prevented.  Digested  with  pepsine, 
peptone  alone  is  formed.     Digested  with  trypsin  and  one 


112  DISEASES    OF    THE    KIDNEY. 

per  cent,  solution  of  sodium  carbonate,  after  some  days 
peptone/with  leucia  and  tyrosin,  are  formed.  Heated  with 
potash,  indol  is  produced.  Boiled  with  sulphuric  acid 
leucin  and  tyrosin  are  formed.  The  aqueous  solution 
gives  with  excess  of  sodium  chloride  and  acetic  acid  a 
precipitate  which  is  soluble  on  the  removal  of  the  salt. 
Oertels  (vide  Ziemssen's  Handbuch  der  Therapie,  1884)  also 
found  this  body  in  the  urines  of  two  individuals,  out  of 
thirty-three,  after  the  ascent  of  considerable  heights.  In 
one  of  the  others  serum  albumin  was  found. 

28.  Bile. — Whenever  the  discharge  of  bile  from  the  liver 
into  the  intestines  is  interrupted,  a  yellow  tinging  (jaun- 
dice) of  the  skin,  as  well  as  of  the  other  tissues  and  fluids, 
takes  place,  owing  to  the  biliary  matters  being  carried  into 
the  circulation.  The  urine  thus  acquires  a  deeper  colour 
varying  from  a  darkish  yellow  to  a  colour  like  London 
Porter,  and  which  gives  a  yellow  stain  to  a  linen  rag  when 
dipped  into  it.  The  tests  for  bile  in  solution  are  those 
that  reveal  the  presence  of  the  bile  pigments,  and  the 
bile  acids. 

(1)  Bile-jngments  fGmelin's  Test).  A  few  drops  of  the 
urine  are  placed  on  a  white  plate,  and  near  them  a  few 
drops  of  nitric  acid  to  which  a  drop  or  so  of  sulphuric  acid 
has  been  added.  The  two  fluids  are  then  slowly  inter- 
mixed by  means  of  a  stirring  rod,  when  if  bile-pigment  be 
present  a  play  of  colours,  of  which  green  is  characteristic, 
is  observed.  As  a  play  of  colours  without  the  develop- 
ment of  distinct  green  is  given  with  other  colouring 
matters,  if  there  is  the  shghtest  doubt  about  the  develop- 
ment of  the  green-tint  the  following  test  should  be  apphed. 

(MarecJialts'  Test).  Float  a  few  drops  of  urine  upon  the 
surface  of  some  tincture  of  iodine  placed  in  a  test-tube  ; 
at  the  point  of  contact  of  the  two  fluids  a  dehcate  green 
colour  will  develope  if  bUe-pigment  is  present. 


BILE.  113 

(2)  Bile  Acids. — Pettenkqfer's  Test  is  difficult  of  ap- 
plication, and  often  unsuccessful  when  applied  after  the 
manner  described  by  most  authors.  I  have  found  the 
method  devised  by  my  friend  Mr.  Francis,  formerly  De- 
monstrator of  Chemistry  at  Charing  Cross  Hospital, 
however,  most  satisfactory  for  clinical  purposes,  and  it 
has  never  failed  to  demonstrate  the  presence  of  bile  acids, 
if  present.  The  method  is,  floating  the  suspected  urine  on 
the  surface  of  sulpho- saccharic  acid.  The  latter  he  directs 
to  be  made  as  follows.  Thhty  grains  of  glucose  dried 
over  a  water-bath,  and  when  quite  cold  to  be  dropped  into 
half  an  ounce  of  strong  sulphuric  acid.  If  the  glucose  is 
quite  dry  no  carbonization  occurs,  and  a  delicate  straw- 
coloured  hquid  is  the  result,  and  which  will  keep  for  several 
days  in  a  closely  stoppered  bottle  excluded  from  the  Hght. 
A  drachm  of  this  placed  in  the  bottom  of  a  test-tube,  and  an 
equal  quantity  of  urine  floated  on  the  surface,  will  give  the 
characteristic  purple  reaction  if  bile  acids  are  present. 
If  there  is  no  time  to  prepare  the  sulpho -saccharic  acid, 
ordinary  glucose  or  honey  does  as  well.  About  five 
grains  of  this  is  added  to  a  drachm  of  urine,  and  the  mix- 
ture floated  over  the  surface  of  strong  sulphuric  acid,  in 
this  case,  however,  more  carbonization  occurs,  which  ob- 
scures the  development  of  colour  reaction,  than  is  the  case 
with  the  first  method. 

In  cases  of  doubt  the  bile  acids  should  be  separated  from 
the  urine  for  the  purpose  of  testing.  To  do  this,  evaporate 
the  urine  to  a  thick  syrup  and  treat  with  ordinary  alcohol. 
Evaporate  this  alcohohc  solution,  and  treat  the  residue 
with  absolute  alcohol.  Evaporate  this  solution  and  dis- 
solve  residue  in  water.  Precipitate  with  neutral  lead 
acetate  and  filter.  Dissolve  the  precipitate  in  alcohol  and- 
decompose  with  sulphydric  acid.  Enter  on  standing,  the 
filtrate  will  deposit  crystals  of  glycocholic  acid.    The  filtrate 


114  DISEASES    OF    THE    KIDNEY. 

which  was  separated  by  filtration,  after  the  precipitation 
with  neutral  lead  acetate  is  now  treated  with  basic  lead 
acetate.  The  resulting  ^precipitate  is  then  treated  in  the 
same  way  as  directed  for  glycohohc  acid  when  taurocholic 
acid  will  separate  out.  This  process  it  is  said  will  detect  the 
presence  of  bile  acids  when  0-001  per  cent,  are  present  in 
the  urine. 

For  the  spectroscopic  examination  of  bUe-pigment  ia 
urine,  and  the  spectrum  of  Pettenkoffer's  test,  see  Colour- 
ing Matters  of  Urine. 

Jaundice  was  formerly  regarded  as  being  either  HcEnia- 
togenous  or  Heptogenous  in  character,  and  many  patholo- 
gists were  led  to  regard  the  presence  or  absence  of  bile 
acids  as  a  diagnostic  point,  being  present  in  the  latter  but 
not  in  the  former.  No  such  distinction  can  be  made, 
since  we  have  increasing  evidence  to  show  that  all  forms 
of  jaundice  are  more  or  less  heptogenous  in  character, 
and  that  in  the  so-called  jaundice  arising  from  blood 
poisoning  (acute  yellow  atrophy,  phosphorus  poisoning, 
pysBmia,  etc.,)  there  is  always  sufficient  catan'h  of  the 
finer  gall-ducts  to  account  for  the  jaundice.  So  that 
though  this  form  of  jaundice  is  x^i'iniarily  caused  by  a 
morbid  condition  of  the  blood,  which  leads  to  catarrh 
of  the  finer  hepatic  ducts,  it  is  absorption  of  bile  al- 
ready formed  by  the  hver  cells,  which  causes  the  jaun- 
dice, and  not  as  was  formerly  supposed  the  conversion  of 
haemoglobin  into  bile-pigment  in  the  circulation.  Traces 
of  bile  acids  are  to  be  found  according  to  Naunym  and 
Dragendorff  in  normal  urines.  In  the  urines  of  dogs,  as 
likewise  bile-pigments,  they  are  even  more  abundant,  and 
very  slight  disturbances  lead  to  then-  increase  ;  an  import- 
ant fact  with  regard  to  any  deductions  made  from  experi- 
ments on  these  animals.  In  cases  of  jaundice  when  there 
is  no  destruction  of  hver-tissue,  the  bile  acids  at  first  are 


BLOOD.  115 

considerably  increased,  gradually  declining  as  the  case 
progresses,  till  they  often  cease  to  ap^Dear.  In  jaundice, 
associated  with  great  destruction  of  liver  tissue,  as  in  acute 
yellow  atrophy,  rapidily  growing  cancer,  etc.,  though  they 
may  be  present  at  an  early  stage,  they  soon  disappear,  and 
as  the  process  is  usually  rapid,  may  not  be  observed  at  all 
during  the  illness.  The  presence  or  absence  from  the 
urine  of  the  bile  acids,  does  not  distinguish  the  nature  of 
the  jaundice  but  only  the  stage  it  has  reached.  As  discolor- 
ation of  the  urine  is  one  of  the  earliest  indications  of  the 
general  tinging  of  the  tissues  and  fluids  with  bile,  so  is 
it  the  first  to  disappear  when  the  obstruction  to  the  flow 
of  bile  into  the  intestines  is  removed,  and  the  iirine  be- 
comes clear  long  before  the  deposited  bile-pigment  is  re- 
moved from  the  skin  and  conjunctiva. 

29.  Blood. — Blood  may  pass  into  the  urine  from  any  por- 
tion of  the  genito-urinary  tract,  and  the  colour  it  imparts 
to  that  secretion  depends  on  the  amount.  A  very  minute 
trace,  one  part  in  1500,  will  give  decided  smokiness,  and 
one  part  in  500  a  bright  cherry-red ;  urine  containing 
blood  is  more  or  less  albuminous,  according  to  the  amount 
of  blood  effused.  Apart  from  the  coloration,  blood  is  re- 
cognised by  the  following  tests. 

a.  Microscopic. — Blood  corpuscles  are  recognised  under 
the  microscope  by  their  peculiar  bi-con- 
cave  form  and  yellowish  tint.      They         fV      r\ 
may,  however,  vary  in  shape.     If  the  O       j! 

urine   is  moderately  acid,  they  retain  q,  (^  ^ 

their  natural  form  for  a  considerable  ~^<%  %     »  q 
time,  but  finally  become  jagged  at  the    @  s^^   O  q 
edges,  lose  colour,  and  do  not  adhere  to    fig.  11.— Blood-cor- 
gether.   In  dilute  urines,  the  corpuscles      puscles  in  unne. 
become  swollen  and  their  concavity  disappears.     In  alka- 
line urines,  the  colouring  matter  soon  dissolves  out. 

i2 


116  DISEASES    OF    THE    KIDNEY. 

b.  Spectroscopic. — A  small  quantity  of  urine  containing 
blood  is  placed  in  a  tube,  and  placed  in  the  slit  of  the 
spectroscope,  distilled  water  is  then  added  till  the  spec- 
trum becomes  quite  clear,  except  between  d  and  e,  where 
there  is  an  intensely  dark  space.  On  further  dilution  this 
gradually  clears  up,  leaving  two  bands,  one  near  d,  with 
well  defined  edges,  and  the  other  near  e,  broader,  less 
shaded  and  defined  at  the  edges.  These  bands  are  charac- 
teristic of  oxy-haemoglobin  ;  by  the  addition  of  reducing 
agents,  these  two  bands  are  rejplaced  by  one  broad  band 
with  diffuse  edges,  midway  between  d  and  e,  this  is  reduced 
haemoglobin.  If  the  urine  has  undergone  decomposition 
then  we  may  have,  if  the  urine  is  acid,  the  spectrum  of  acid 
haematin  which  gives  one  broad  band  between  o  and  d,  but 
nearer  to  c.  If  the  urine  is  alkaline,  then  we  may  have 
the  spectrum  of  alkaline  haematin,  this  band  instead 
of  being  nearer  to  c,  approaches  nearer  to  d,  whilst 
the  blue  end  of  the  spectrum  becomes  more  obscure. 
In  some  instances  especially  in  hemoglobinuria,  the 
spectrum  of  methsemoglobin  will  be  observed,  this 
closely  resembles  that  of  acid  haematin,  for  which  it 
has  been  often  mistaken,  it  is  however  midway  between 
c  and  D,  whilst  in  acid  hsematin  the  band  approximates 
closely  to  c. 

c.  Hcemin  Crystals. — Boil  the  urine  in  a  test-tube  to  pre- 
cipitate any  albumin  present,  adding  liquor  potassas  to 
throw  down  the  earthy  phosphates.  Collect  the  pre- 
cipitate which,  if  blood  be  present,  will  be  tinged  red,  dry  it 
and  treat  it  with  alcohol  containing  sulphuric  acid.  This 
solution  contains  hematin.  Evaporate  this  solution,  and 
then  add  a  few  grains  of  common  salt,  place  the  residue 
on  a  glass  slide,  add  a  drop  or  two  of  glacial  acetic  acid 
cover  the  mixture  with  a  thin  glass|'shp,  and  gently  heat 
the  whole.      Examine  when  cold,  when  minute  bluish- 


BLOOD.  117 

red  crystals  of  li^miu  will  be  found  dispersed  through  the 
residue. 

d.  Guaiacum  Test— Place  a  drachm  of  tincture  of  guaiacum 
in  a  test-tube,  then  add  a  drop  of  the  suspected  urine,  and 
then  float  on  the  surface  an  etherial  solution  of  hydrogen 
peroxide ;  if  blood  is  present  a  blue  ring  will  immediately 
form  at  the  junction  of  the  etherial  solution  and  the  guaia- 
cum. This  is  an  extremely  delicate  test  for  blood  when  pre- 
sent, but  as  other  substances  besides  blood,  that  may  be 
present  in  urine,  give  the  reaction,  it  is  not  to  be  relied  on 
as  sole  evidence  as  to  the  presence  of  blood. 

Two  forms  of  bloody  urine  are  recognised  clinically. 
(1)  Hematuria  in  which  the  colouring  matter  is  associated 
with  the  red  corpuscles  ;  (2)  hsemoglobinuria,  or  h^mina- 
turia,  in  which  the  blood  corpuscles  are  absent. 

(1)  HiEMATUEiA. — Nejjhritis.  Frequent  in  early  stages  of 
acute  nephritis,  urine  smoky  to  reddish-brown,  blood  uni- 
formly diffused  through  the  urine  which  is  generally  acid. 
Excess  of  albumin,  hyaline  and  epithelial  casts,  dropsy ; 
less  frequent  in  sub-acute  nephritis,  and  only  then  attend- 
ant on  fresh  exacerbations  of  the  disease ;  uncommon  in 
chronic  nephritis,  and  then  only  of  incidental  occurrence 
in  common  with  haemorrhages  from  other  mucous  surfaces. 

Calculous  jjyelitis.  Often  considerable  after  exercise,  di- 
minishing when  the  patient  is  kept  quiet  in  bed,  when  only 
a  few  blood  corpuscles  may  be  found  by  the  microscope. 
Blood  uniformly  diffused  through  the  urine  which  is  gen- 
erally acid.  Pus  cells  always  present  in  the  urine,  and  the 
amount  of  albumin  proportionate  to  the  amount  of  blood. 
Generally  accompanied  with  colic  and  retraction  of  testicle 
on  the  side  affected.  Hematuria  may  occur  in  other  forms 
of  pyehtis,  besides  that  due  to  calculus  in  the  kidney,  but 
is  rarely  severe  or  persistent. 

Cancer  of  Kidney,     Haemorrhage  often  very  profuse  with 


118  DISEASES    OF    THE    KIDNEY. 

large  clots,  and  fibrinous  moulds  of  ureters,  etc.  Generally 
accompanied  -with  swelling  in  the  loin,  rapidly  increasing 
in  size.  Large  caudate  cells  of  swollen  columnar  epithe- 
lium from  pelvis  of  kidney  often  present,  may  be  taken 
for  cancer  cells.     Urine  generally  acid. 

Disease  of  Bladder,  Prostate  and  \  Urethra  from  cys- 
titis, abcess,  cancer,  stone,  gonorrhoea,  etc.  Blood  often 
profuse,  and  the  urine  containing  much  mucus.  In  many 
cases  the  urine  first  passed  is  clear  or  at  the  most  only 
smoky,  but  towards  the  end  of  micturition  becomes  more 
and  more  bloody.  If  due  to  stone  or  cancer,  the  mass 
can  usually  be  detected  by  sounding.  The  urine  is 
generally  thick  with  muco-pus,  and  is  often  alkaline. 

Morbid  conditions  of  the  Blood,  as  in  scurvy,  purpuric 
small-pox,  measles,  enteric  fever,  rheumatism.  In  rare 
cases  hsematuria  has  been  known  to  precede  an  attack  of 
frank  gout,  and  in  a  markedly  intermittent  form  as  asso- 
ciated with  a  malarial  taint.  In  these  cases  though  the 
hemorrhage  may  be  profuse,  clots  rarely  form  in  the  urine. 

Heart  Disease.  Hsematuria  sometimes,  though  rarely, 
occurs  in  valvular  disease  of  the  heart,  consequent  on  the 
venous  congestion. 

Endemic  Haviaturia.  The  urine  deposits  dirtyish- white 
flocculent  matter,  containing  short  filaments  of  brownish 
colour  and  soft  consistence,  and  larger  reddish  masses  like 
blood  clots,  also  highly  refractive  bodies,  which  may  be 
identified  as  the  ova  of  the  Bilharzia  hsematobium. 

(2)  HEMOGLOBINURIA. — In  thcsc  cases  the  urine  contains 
the  colouring  matter  of  the  blood,  but  not  red  corpuscles. 
It  is  probable  that  the  colouring  matter  is  dissolved  out 
from  them  in  the  blood,  very  likely  the  change  occurs  in 
the  liver  (see  Functional  Albuminuria).  The  urine  has  a 
port  wine  colour,  and  is  usually  passed  clear.  It  is  al- 
ways albuminous.      On  standing  it  deposits  a  brownish 


SUGAE.  119 

sediment  consisting  of  tube  casts,  epithelium,  crystals  of 
oxalate  of  lime,  and  crystals  of  lisematin  have  been  ob- 
served. The  spectrum  of  this  urine  often  exhibits  the 
presence  of  methsemoglobin,  in  addition  to  that  of  oxy- 
Jisemoglobin.  The  attacks  are  paroxysmal,  and  preceded 
by  chills,  and  are  generally  accompanied  by  a  feeling  of 
nausea,  epigastric  pain,  and  slight  jaundice. 

30.  Sug^ar^  CeHiaOe  (Glucose). — Normal  urine  contains 
minute  traces  of  glucose,  about  "05  grm.  being  passed  in 
the  twenty-four  hours.  This  quantity  may  be  enormously 
increased  by  circumstances  which  disturb  the  hepatic  func- 
tion, so  that  the  amount  passed  out  of  the  system  daily  can 
sometimes  be  measured  by  ounces.  When  the  drain  of 
sugar  from  the  body  is  persistent  or  is  only  held  in  check  by 
diet,  the  disease  is  termed  "diabetes  meUitus,"  when,  how- 
ever, the  sugar  is  present  in  smaller  quantities,  and  disap- 
pears on  treatment,  the  derangement  is  spoken  of  as  "  gly- 
cosuria." The  tests  for  sugar  in  urine  are  numerous,  but 
it  will  only  be  necessary  to  consider  three,  those  most 
generally  in  use,  at  length,  merely  enumerating  the  others 
which  may  be  employed  as  confirmatory,  or  employed  if 
by  any  chance  the  others  are  not  obtainable. 

(1;  Alkaline  Coijper  Test. — This  test  is  based  on  the  fact 
that  alkaline  solutions  of  glucose  possess  the  property, 
when  heated,  of  reducing  salts  of  cupric  oxide  to  cuprous 
oxide ;  the  cuprous  oxide  being  deposited  as  a  red  pre- 
cipitate at  the  bottom  of  the  tube  or  flask ;  thus  : — 

Glucose.  Potassium  Hydrate.    Cupric  Sulphate. 

^C,B..Jd,   +    2KH0       +     2CuS0, 

Glucose.  Potassium  Sulphate.    Cuprous  Oxide. 

=   2C6H12O6     +     2KHSO4       -f         CU2O 

This  test  is  known  as  Trommer's;  as,  however,  certain 
organic  substances  if  present  in  excess  in  the  urine  may 
cause  the  precipitate  to  redissolve,  it  is  necessary  for  urine 


120  DISEASES    OF    THE    KIDNEY. 

testing  to  employ  a  substance  whicli  will  prevent  this 
taking  place,  and  this  is  done  by  adding  tartaric  acid  in  the 
form  of  Eochelle  salt,  sodio-]potassium  tartrate,  to  the  al- 
kaline copper  solution  (see  Appendix,  No.  7),  the  reagent 
thus  prepared  is  known  as  "  Fehling's  test  solution." 

There  are  many  modifications  of  Fehling's  test  solution, 
notably  those  of  Pavy  and  Piffard,  but  they  are  all  based 
on  the  same  principle,  and  consist  of  cupric  sulphate  with 
a  caustic  alkali,  and  a  tartrate  of  soda,  potash  or  ammonia. 
These  solutions  are  used  both  for  the  qualitative  and 
quantitative  determination  of  sugar.  For  the  quahtative 
estimation  of  sugar,  the  procedure  is  as  follows. 

Place  two  cubic  centimetres  of  Fehling's  solution  in  a 
test-tube,*  and  carefully  heat  to  the  boiling  point;  then 
set  it  aside  for  a  short  time  till  nearly  cool ;  if  no  deposit 
ensues  on  cooling,  it  shows  the  solution  is  in  good  order. 
The  temperature  is  again  raised  to  boiling  point,  and  then 
one  drop  of  urine  is  to  be  added,  if  sugar  is  present  in  any 
amount  a  yellow  precipitate  will  form,  which  will  become 
redder  by  exposure  or  prolonged  heating.  If  only  a  very 
small  quantity  of  sugar  be  present,  the  colour  will  be 
greenish  rather  than  yellow,  in  this  case  a  drop  or  so  more 
urine  must  be  added  when  the  characteristic  yellow  colour 
will  develop.  In  applying  this  test,  the  following  precau- 
tions must  be  observed,  (a)  That  the  solution  is  in  good 
order ;  by  keeping  the  tartaric  acid  is  converted  into 
racemic  acid,  which  has  the  power  of  reducing  copper 
when  heated,  the  test  solution  should  therefore  always  be 
tried  in   the  manner  directed  above  before  the  urine  is 

*  Since  the  test  liquids  keep  better  when  the  cupric  solution  is 
preserved  distinct  from  the  alkaline  tartrate  solution,  it  is  advisable 
not  to  mix  them  till  required,  but  store  them  in  separate  bottles  and 
then  for  qualitative  testing  to  add  one  cubic  centimetre  of  cupric 
solution  to  one  cubic  centimetre  of  alkaline  tartrate  solution. 


SUGAK.  121 

added,  (h)  To  avoid  adding  an  excess  of  urine,  since 
excess  of  sugar  dissolves  the  suboxide,  and  instead  of  a 
precipitate  we  get  only  a  reddish  yellow  solution. 
fc)  Uric  acid  and  kreatinin  when  in  excess  have  the  power 
of  reducing  Fehling's  solution,  if  any  doubt  exists  as  to 
whether  the  reduction  is  due  to  this  cause  or  to  sugar, 
lead  acetate  must  be  added  to  the  urine  before  testing, 
this  precipitates  the  uric  acid,  etc. ;  if  therefore  the  reduc- 
tion was  due  to  these  substances,  no  reaction  will  occur 
after  their  precipitation  aiid  removal  by  filtration.  Besides, 
uric  acid  gives  no  reaction  with  either  the  indigo- carmine 
or  the  yeast  test,  (d)  Although  inosite  does  not  reduce 
Fehling's  solution,  an  olive-green  cloudy  precipitate  is 
separated,  which  may  be  mistaken  for  that  given  with 
urine  containing  only  a  trace  of  sugar,  it  may  be  distin- 
guished however  by  the  fact  that  if  the  precipitate  caused 
by  inosite  be  removed  by  filtration,  and  the  filtrate  again 
boiled,  the  same  greenish  cloud  will  again  form.  Inosite, 
however,  according  to  Dr.  Oliver,  {Op.  cit.,  p.  92)  reduces 
indigo-carmine.  The  following  medicinal  agents  give  a 
reaction  with  Fehling;  unoxidised  phosphorus,*  ammo- 
nium sulphide,*  iron  sulphate,*  gallic*  and  tannic*  acids, 
gelsemium,  chloroform,  resin.  Those  substances  marked 
with  an  asterisk,  according  to  Dr.  Oliver's  careful  experi- 
ments, give  reaction  with  indigo- carmine  and  picric  acid 
as  well,  fe)  Urine  containing  an  excess  of  earthy  phos- 
phates when  added  to  the  alkaline  copper  solution,  will 
throw  down  greyish  flocks  of  precipitated  phosphates,  they 
are  readily  distinguished,  however,  from  the  precipitate  of 
reduced  copper  by  the  absence  of  any  tinge  of  red  or  yel- 
low, and  by  their  floating  in  the  clear  bluish-green  solution. 
(f)  In  all  cases  the  urine  should  be  freed  from  albumin, 
if  present,  before  applying  the  test. 

For  bedside  purposes,  the  cupric  test  can  be  applied  by 


122  DISEASES    OF    THE    KIDNEY. 

means  of  Dr.  Oliver's  prepared  papers,  or  Dr.  Pavy's 
pellets,  or  as  I  suggested  in  1880,  {Lancet,  vol.  ii.,  p.  192), 
in  small  glass  capsules,  each  containing  one  cubic  centi- 
metre of  FehlLng's  solution,  supplied  by  Martindale,  New 
Cavendish  Street. 

The  quantitative  determination  of  sugar  by  means  of 
Fehhng's  solution  is  described  in  Ajypendix  I.,  No.  7. 

(2)  Indigo- Carmine  Test. — This  has  lately  been  re-intro- 
duced by  Dr.  Ohver,  and  he  has  made  it  readily  available 
by  means  of  his  specially  prepared  test  paper.  It  is  based 
on  the  fact  that  glucose  and  certain  carbo-hydrates  when 
heated  in  the  presence  of  an  alkah,  have  the  power  of  re- 
ducing indigo-blue  to  indigo- white,  thus  : — 

Indigotin.  Indigo-White. 

2(C8H,NO)  -}-  H2  =  CieHi^N.O^ 

To  apply  this  test,  render  the  urine  alkaline  by  means  of 
a  little  sodium  carbonate,  and  then  add  a  few  drops  of 
sulpho-indigotate  of  sodium  (indigo-carmine),  and  then 
heat  in  a  test-tube,  care  being  taking  not  to  boil  or  shake 
the  fluid,  after  a  while  the  blue  solution  changes  colour 
passing  rapidly  from  blue  to  violet  to  red  and  finally  to  a 
pale  yellow  or  white ;  on  shaking  the  mixture  the  blue 
colour  is  restored,  owing  to  the  reconversion  of  the  indigo- 
white  to  indigo-blue  under  the  influence  of  oxygen.  As 
the  solutions  required  for  this  test  undergo  a  gradual 
change  on  keeping.  Dr.  OHver's  prepared  test-papers,  which 
are  very  stable  if  kept  dry,  are  the  best  for  its  application. 
A  paper  charged  with  indigo  and  sodium  carbonate  is 
placed  in  a  test-tube  and  covered  with  distilled  water 
(spring  water  will  do  but  if  very  hard  the  solution  is  not 
clear  though  it  does  not  interfere  with  the  reaction),  and 
then  apply  heat,  till  the  fluid  in  the  test-tube  is  deeply 
blue.  Then  add  one  drop  of  m-ine  and  boil  for  about  ten 
or   twenty   seconds,    then   raise  the  test-tube  above  the 


SUGAR.  123 

flame  of  the  spirit  lamp  so  that  the  mixture  is  kept  hot, 
but  does  not  boil,  taking  care  also  not  to  shake  the  fluid, 
and  in  a  short  time  (about  five  seconds  if  the  quan- 
tity of  sugar  is  large,  over  twenty  grains  to  the  ounce, 
and  thirty  to  sixty  seconds  if  small),  the  change  of 
colour  will  take  place  ;  now  shake  the  tube  and  the  blue 
colour  will  be  restored.  Should  the  urine  be  highly  acid, 
or  the  water  in  which  the  indigo  is  dissolved  be  very 
hard,  it  is  advisable  to  add  a  Uttle  more  alkali,  which  can 
be  done  by  dropping  into  the  mixture  an  extra  sodium 
carbonate  paper.  This  precaution  is  necessary  as  in  a 
case  of  diabetes  in  which  there  was  an  excess  of  sugar, 
and  the  urine  highly  acid,  I  failed  to  get  the  reaction  till  I 
had  made  this  addition.  In  carrying  out  this  test,  as 
indeed  in  all  analytical  procedures,  it  is  important  to  see 
that  the  test-tubes  are  perfectly  clean,  since  a  trace  of  nitric 
acid,  liquor  potassse,  Fehling's  solution,  or  decomposing 
urine  may  modify  considerably  the  reaction.  The  indigo 
test  is  not  only  useful  in  itself  for  determining  the  presence 
of  sugar  but  is  a  valuable  supplement  to  Fehling's,  since 
the  latter  is  reduced  by  uric  acid  and  kreatinin  whereas 
the  indigo  test  is  unaffected.  It  is  also  useful  in  de- 
termining a  small  amount  of  sugar  in  the  presence  of 
much  albumin,  pus,  blood,  etc.,  since  these  bodies  do  not 
interfere  with  the  reaction,  as  is  the  case  with  Fehling's 
solution,  before  the  application  of  which  they  have  to  be 
removed. 

(3)  Fermentation  Test. — This  requires  time,  but  is  an  ex- 
tremely valuable  test  especially  as  affording  a  rough 
clinical  indication  of  the  amount  of  sugar  present.  For 
this  purpose  the  differential  process  recommended  by 
Eoberts  is  the  one  usually  employed,  and  is  as  follows  : — 
The  urine  is  collected  for  twenty- four  hours  and  carefully 
measured,  and  four  ounces  of  this  is  taken  and  placed  in  an 


124  DISEASES    OF    THE    KIDNEY. 

eight-ounce  bottle  together  with  a  small  piece  of  yeast, 
and  in  another  bottle  of  the  same  size  a  similar  quantity 
of  urine  but  no  yeast.  The  two  bottles  are  now  to  be  put 
aside  in  a  warm  place  for  twenty-four  hours,  and  after  the 
lapse  of  that  period,  the  contents  of  each  having  been 
poured  into  two  urine  glasses  their  respective  specific 
gravities  are  to  be  taken.  The  difference  of  each  degree  lost 
in  the  urine  which  has  the  yeast,  indicates  the  p7"esence  of  one 
grain  of  sugar  in  every  fluid  ounce  of  urine.  For  example,  if 
a  patient  passes  160  ounces  of  urine  in  the  twenty-four 
hours  ;  and  the  specific  gravity  of  the  urine  in  the  bottle 
without  the  yeast  is  1*042,  and  in  the  bottle  with  yeast 
1*033  or  nine  degrees  less  (which  represents  the  loss  oc- 
casioned by  the  formation  of  carbonic  acid),  then  as 
each  degree  lost  represents  one  grain  of  sugar ;  the  160 
ounces  multiplied  by  9  gives  1440  grains  of  sugar  passed 
in  the  twenty-four  hours.  If  French  measures  are  em- 
ployed, then  each  degree  of  specific  gravity  lost  represents- 
0*2196  gramme  of  sugar  in  every  100  c.c.  of  urine. 

In  emxjloying  this  test  it  is  advisable  to  use  a  urinometer 
with  a  long  index,  so  as  easily  to  read  off  the  variation  in 
the  number  of  degrees,  and  always  to  use  the  same  in- 
strument in  recording  the  observations  in  any  given  case, 
since  these  instruments,  especially  those  that  have  been  in 
long  use  in  hospital  wards,  rarely  accord  with  one  another. 
If  these  particulars  are  attended  to,  very  close  results  will 
be  obtained,  quite  sufficient  to  show  the  daily  variations  in 
the  amount  of  sugar  as  influenced  by  diet,  etc.,  although  it 
is  advisable  from  time  to  time,  say  once  every  fortnight  ta 
make  a  correct  determination  by  means  of  Fehling's  stand- 
ard solution. 

If  definite  results  have  been  obtained  by  means  of  the 
alkahne  cupric  test,  the  indigo- carmine  reaction,  and  by 
fermentation,  our  enquiry  need  not  be  carried  further  as 


SUGAK. 


125 


these  tests  are  in  themselves  conclusive,  and  as  these 
reagents  are  readily  available  they  are  the  tests  most 
likely  to  be  resorted  to.  It  will  therefore  be  sufficient 
merely  to  enumerate  the  other  reactions  of  glucose  with- 
out entering  into  details.  (a)  Moore's  Test.  A  brownish 
colour  developed  on  boiling  saccharine  urine  with  liquor 
potassaB.  (h)  Butteker's  Test,  Equal  volumes  of  urine  and 
liquor  potass^  are  mixed  together  in  a  test-tube,  and  two 
or  three  grains  of  bismuth  subnitrate  dropped  into  the 
mixture,  which  is  then  boiled,  when  sugar  if  present  will 
reduce  the  bismuth  to  its  metallic  state  and  it  will  fall  as 
a  black  precipitate.  If  the  sugar  is  only  in  very  small 
quantity  the  precipitate  will  be  only  greyish,  in  this  case 
more  urine  and  alkali  must  be  added,  and  the  mixture 
again  boiled.  Albumin  and  unoxidized  sulphur  are  the 
only  products  likely  to  be  met  with  in  urine,  besides  sugar, 
that  give  a  similar  reaction  with  bismuth  salts,  (c)  Picric 
Acid  Test.  The  urine  is  rendered  alkahne  by  hquor  po- 
tassse  and  a  grain  or  so  of  picric  acid  added  to  the  mixture, 
which  is  then  heated,  when  if  the  smallest  trace  of  sugar  is 
present  a  deep  mahogany-brown  coloration  will  develop, 
caused  by  the  conversion  of  picric  into  picramic  acid. 
Normal  urine  when  heated  with  hquor  potassee  and  picric 
acid  acquires  a  distinctly  brownish  colour,  but  the  colora- 
tion is  never  so  deep  as  is  the  case  if  the  most  minute 
trace  of  sugar  is  present.  Dr.  G.  Johnson  has  devised  an 
exceedingly  ingenious  method  of  quantitatively  estimating 
the  amount  of  sugar  by  the  depth  of  colour  yielded  by 
this  reaction  as  compared  with  a  standard  colour  prepared 
for  comparison,  an  account  of  which  is  given  in  Clinical 
Chemistry,  p.  157.  (d)  Polarimetnj.  Glucose  possesses 
the  property  of  rotating  polarized  light  towards  the  right. 
This  property  has  been  made  use  of  to  determine  the 
amount  of  sugar  present  in  urine,  by  the  amount  of  devia- 


126  DISEASES    OF    THE    KIDNEY. 

tion  observed,  which  is  done  by  means  of  an  instrument 
called  a  saccharometer.  The  procedure  requires  a  con- 
siderable amount  of  special  skill  and  training,  and  as  it  is 
not  generally  available  for  clinical  purposes,  is  not  de- 
scribed here,  the  reader,  however,  will  find  an  account  in 
Clinical  Chemistry,  p.  158,  and  in  other  works  more  es- 
pecially devoted  to  chemistry  and  physics.  The  specific 
dextro-rotatory  power  of  glucose  may  be  stated  however, 
it  is  -|-  57*6°.  (e)  Torula  cerevisicB  or  yeast  plant  always 
developes  in  saccharine  urine,  and  forms  a  characteristic 
white  scum  on  its  surface,  and  is  associated  with  peni- 
cillium  glaucum  or  mildew.  It  forms  oval  vesicles  about 
the  size  of  a  blood  corpuscle  in  which  stage  it  cannot 
be  distinguished  from  the  other,  the  thallus,  however,  of 
the  torula  bears  a  brownish  coloured  spherical  head  of 
sporules. 

The  pathological  significance  of  sugar  in  urine  will  be 
fully  considered,  when  we  come  to  consider  the  morbid 
conditions  of  urine  dependent  on  functional  derangements, 
(Diabetes) . 

31.  Inosite  [Muscle  sugar). — Inosite  is  occasionally  pre- 
sent in  urine  as  a  morbid  product,  to  obtain  it  the  urine  is 
completely  precipitated  with  sugar  of  lead,  filtered,  and 
the  warm  filtrate  treated  with  basic  acetate  of  lead  as  long 
as  any  precipitate  is  formed.  It  is  better  that  the  urine 
should  be  concentrated  to  one-fourth  before  it  is  precipi- 
tated. The  lead-precipitate  collected  after  twelve  hours' 
standing  is  washed,  suspended  in  water,  and  then  decom- 
posed by  sulphuretted  hydrogen.  After  the  filtrate  has  been 
left  at  rest  a  short  time,  a  small  quantity  of  uric  acid 
separates  from  it ;  this  is  removed  by  filtration,  and  the 
fluid  so  concentrated  as  to  remain  permanently  turbid, 
when  treated  with  an  equal  volume  of  alcohol.  It  is  then 
heated  until  the  turbidity  disappears,  and  allowed  to  stand 


INOSITE.  127 

one  or  two  days.  The  crystalline  mass  thus  obtained  is 
purified  by  re-crystaUisation.  Inosite  either  separates  in 
large  rhombic  tables,  or  in  small  tufted  groups  of  oblique 
prisms.  The  crystals  are  soluble  in  six  parts  of  water  at 
20°  C.  Their  solutions  do  not  undergo  vinous  fermentation, 
but  readily  take  on  lactic  acid  fermentation.  They  do  not 
reduce  Fehling's  solution,  but  turn  it  an  olive-green,  and 
after  a  while  a  flocculent  precipitate  falls,  and  the  super- 
natant fluid  becomes  blue,  on  filtering  off  the  precipitate 
and  again  heating  the  solution,  the  olive-green  colour  is 
again  developed.  Another  delicate  test  is  to  evaporate  a 
pure  solution  of  inosite  to  which  a  drop  or  two  of  nitric 
acid  has  been  added,  to  near  dryness,  then  touch  the  resi- 
due successively  with  ammonia  and  solution  of  calcium 
chloride,  and  then  dry  slowly,  when  a  rosy-red  colour 
will  develop. 

The  pathological  significance  of  the  presence  of  inosite 
in  urine  has  not  been  yet  worked  out.  It  has  been  found 
as  an  occasional  constituent  in  certain  diseases,  diabetes, 
Bright's  disease,  phthisis,  in  syphilitic  cachexia,  and  in 
typhus.  Writing  in  1880  (Demonstrations  Phys.  and  Path. 
Chem.)  I  stated  that  the  pecuHar  reaction  with  Fehling's 
solution  as  stated  above,  was  often  to  be  observed  in  ex- 
amining urines,  and  Dr.  Oliver  {oj}.  cit.  p.  87),  has  since  con- 
firmed my  observation,  so  that  it  is  possible  that  inosite 
does  appear  in  the  urine  more  frequently  than  is  generally 
supposed.  In  the  cases  I  have  met  with,  there  has  been 
usually  some  polyuria  though  not  excessive,  loss  of  flesh, 
general  malaise,  and  always  considerable  aching  of  the 
limbs,  in  these  instances  no  tangible  disease  was  present. 
Again  it  is  not  at  aU  uncommon  to  meet  with  this  reac- 
tion in  the  intermittent  forms  of  glycosuria,  when  for  some 
days  the  copper  has  been  fuUy  reduced,  and  then  only  this 
olive-green  coloration  -appears.  The  subject  is  deserv- 
ing of  more  attention  than  has  yet  been  paid  to  it. 


128 


DISEASES    OF    THE    KIDNEY. 


32.  Lactose^  C12H22OU+H2O  (Milk  Sugar). — Lactose  is 
not  infrequently  met  with  in  the  urine  of  sucHing  women, 
sometimes  in  such  quantities  as  to  resemble  true  diabetes. 
A  case  of  this  kind  has  been  under  my  observation  at 
the  London  Hos^Dital.  A  young  married  woman,  aged 
twenty-nine,  who  was  suckling  her  second  child,  appHed 
as  an  out-patient  in  November  1881,  suffering  from  debility 
with  frequent  and  excessive  micturition.  The  urine  was 
examined  and  found  to  contain  about  three  per  cent,  of 
sugar,  she  remained  under  treatment  till  January,  and 
then  ceased  attendance.  In  April  1882,  she  applied 
again  for  some  other  complaint,  and  stated  that  she  was 
again  pregnant,  and  that  since  she  had  been  so,  the  dia- 
betic symptoms  had  disappeared,  there  was  then  no  sugar 
in  the  urine.  She  was  confined  towards  the  end  of  the 
year,  and  again  sugar  was  found  in  the  urine,  but  not  to 
the  same  extent  as  on  the  previous  occasion.  She  became 
pregnant  again  about  June,  1883,  and  was  confined  in 
March  1884,  early  in  May  she  came  again  to  the  hospital, 
complaining  that  the  symptoms  had  returned  with  great 
severity,  but  that  she  had  been  completely  free  from  them 
during  her  term  of  pregnancy.  On  examining  the  urine  it 
was  found  to  contain  an  abundance  of  sugar,  she  is  still 
under  observation,  and  the  amount  of  sugar  has  been  di- 
minished by  the  administration  of  opium.  The  child  has 
been  weaned.  It  has  been  shown  that  the  sugar  in  these 
cases  is  not  glucose,  but  lactose,  as  proved  by  the  dextro- 
rotatory power  being  +  59'3°,  instead  of  -j-  57"6°,  and  from 
characteristic  crystals  of  lactose  being  obtained  from  the 
urine.  Lactose  gives  the  same  reaction  with  Fehling's 
solution  and  indigo- carmine  that  glucose  does,  it  is  not, 
however,  so  readily  fermentable  with  yeast. 

33.  Laevulose,  CsHiaOg  (Invert  Sugar)  has  been  found 
by   some  observers  in    the  urine    of  persons    suffering 


ALKAPTON.  129 

from  symptoms  analogous  to  tliose  of  diabetic  patients, 
with  or  without  glucose.  It  can  be  distinguished  from 
glucose  by  the  fact  that  it  turns  the  plane  of  polarisa- 
tion to  the  left  instead  of  to  the  right.  This  rotatory 
power  diminishes  as  the  temperature  rises,  being  — 106° 
at  15°  C  ;  —79-5  at  52°  C,  and  —53°  at  90°  C.  Lsvulose 
reduces  alkaline  copper  solution  like  glucose.  I  have 
never  met  with  a  case  similar  to  those  that  have  been  de- 
scribed, but  I  can  readily  imagine  that  the  excessive  in- 
gestion of  cane  sugar,  and  the  sugars  of  certain  kinds  of 
fruits  might  cause  the  appearance  of  invert  sugar  in  the 
urine,  especially  in  the  case  of  disturbed  digestion,  or  too 
rapid  absorption,  since  we  know  that  in  the  intestines  cane 
sugar  is  converted  into  a  mixture  of  glucose  and  Isevulose. 
34.  Alkapton. — A  yellowish  resinous  body  is  occasion- 
ally found  in  urine,  which  by  exposure  to  air  acquires  a 
brownish  tint,  and  so  stains  the  linen.  It  was  first  dis- 
covered by  Bodecker  in  the  urine  of  a  man  convalescent 
from  typhus  fever.  It  does  not  ferment,  and  does  not 
reduce  bismuth  like  glucose,  though  it  throws  down  a 
somewhat  brownish  mass.  Dr.  Maguire  {Brit.  Med. 
Journal,  Oct.  25th,  1884),  thinks  that  pyro-catechin  which 
sometimes  appears  in  human  urine  is  the  same  as 
Bodecker's  alkapton.  With  Fehling's  solution,  it  gives 
peculiar  reactions  according  to  the  amount  of  solution 
used.  If  only  a  smaU  quantity  of  copper  is  added  to  the 
alkaline  tartrate  solution,  on  adding  the  urine  containing 
alkapton  the  sub-oxide  will  not  be  deposited,  but  the  solu- 
tion acquires  a  yellow  colour.  If  the  copper  be  in  excess, 
the  sub-oxide  is  precipitated  as  with  glucose,  as  a  yellow  pre- 
cipitate  which  rapidly  becomes  a  brilliant  red.  Basic  lead 
acetate  gives  a  white  precipitate,  which  on  exposure  to  air 
acquires  a  brownish- violet  colour.  It  can  be  separated 
from  urine  by  precipitating  with  basic  lead  acetate,  the  pre- 

E 


130  DISEASES    OF    THE    KIDNEY. 

cipitate  collected  and  suspended  in  water,  and  the  mixture- 
decomposed  with  hydrogen  sulphide.  The  filtrate  is  then 
evaporated  and  triturated  with  barium  sulphate,  and  then 
exhausted  with  ether.  A  brown  mass  is  left  on  the  eva- 
poration of  the  ether,  this  must  be  dissolved  in  water  and 
precipitated  with  neutral  lead  acetate,  and  the  filtrate 
treated  with  basic  lead  acetate.  This  precipitate  is  then 
suspended  in  water  and  decomposed  by  hydrogen  sulphide.. 
The  filtrate  is  then  evaporated,  when  the  alkapton  will  be 
deposited  as  a  yellowish  resinous  substance  highly  soluble- 
in  water,  but  only  sparingly  in  ether. 

35.  Leucin  and  Tyrosin. — Leucin  and  tyrosin  when 
met  with  in  the  urine  are  invariably  associated  together,, 
though  their  relative  proportions  vary  greatly  in  different 
cases. 

Leucin,  CsHigNOa,  separates  from  urine  in  the  form  of  cir- 
cular oily  discs  (fig.  12,  a)  of  a  yellowish  colour.  To  obtain 
it  in  a  pure  and  crystalline  state,  evaporate  the  urine  to- 
dryness,  and  dissolve  the  residue  in  boihng  alcohol,  on  cool- 
ing leucin  will  be  deposited  in  white  shining  plates  greasy 
to  the  touch,  lighter  than  water,  much  resembling  choles- 
terin  in  a^Dpearance,  but  distinguished  from  that  body  by 
being  insoluble  in  ether. 

Tyrosin,  CgHuNOs,  is  obtained  from  urine  by  precipi- 
tating the  colouring  and  extractive  matters  with  basic  lead 
acetate,  and  decomposing  the  filtrate  with  sulx^hydric  acid 
and  filtering.  The  clear  filtrate  is  then  evaporated  to  a 
thin  syrup,  on  cooling  crystals  of  tyrosin  will  be  deposited.. 
The  crystals  (fig.  12,  h,  c),  are  long  prismatic  needles, 
which  cluster  together  to  form  stellate  masses  or 
spherical  balls.  The  crystals  are  sparingly  soluble  in  cold 
water  and  alcohol,  but  soluble  in  alkaline  and  acid  solu- 
tions. Warmed  with  a  few  drops  of  sulphuric  acid,  a 
solution  of  tyrosin  gives  after  neutralization  with  barium 


TYROSIN.  131 

carbonate,  a  violet  reaction  with  ferric  chloride.  Solutions 
of  tyrosin  heated  with  a  mixture  of  mercuric  and  mer- 
curous  nitrate  give  a  red  colour. 

When  these  bodies  are  in  great  excess,  the  mere  eva- 
poration of  a  drop  of  urine  on  a  glass  slide  is  sufficient  for 
their  detection  ;  they  then  appear,  the  tyrosin  as  sheaf- like 

^"'■^'"'^'^^ 

b  c 

Fig.  12. — Leucin  and  Tyrosin. 

bundles  of  fine  acicular  needles,  and  yellowish- green 
globules,  the  leucin  in  lumpy  globular  masses  (fig.  12,  a). 
The  presence  of  these  bodies  denote  rapid  and  extensive 
destruction  of  the  liver  cells.  Hence  they  are  met  with  in 
the  urine  in  acute  yellow  atrophy  of  the  liver  and  phos- 
phorous poisoning,  in  malignant  forms  of  typhus  and 
small-pox.  Eecently  Dr.  Anderson  (Med.  Chir.  Trans.  ^ 
vol.  xiii.),  has  stated  that  these  bodies  are  to  be  found 
more  frequently  in  urine,  than  has  hitherto  been  allowed, 
and  that  they  are  to  be  met  with  under  numerous  patho- 
logical conditions,  which  affect  the  liver  either  intrinsi- 
cally or  from  without.  This  statement,  however,  requires 
confirmation,  but  it  is  not  improbable  that  if  we  looked 
more  closely  for  these  bodies,  we  might  meet  with  them 
more  frequently.  With  regard  to  the  relative  proportions 
of  these  bodies  present  in  any  given  case,  my  experience 
leads  me  to  the  conclusion  that  tyrosin  is  more  abundant 
in  acate  and  rapid  cases,  whilst  excess  of  leucin  seems  to 
denote  a  more  chronic  course. 

k2 


132 


DISEASES    OF    THE    KIDNEY. 


36.  Cystin,  C3H7NSO2.— Cystin  forms  a  somewhat 
rare  variety  of  uriuary  calculus,  and  is  still  more  rare  as  a 
deposit.  When  present  it  may  be  separated  from  urine  by 
adding  excess  of  acetic  acid,  and  allowing  the  mixture  to 
stand  some  hours.  The  deposit  is  then  collected,  dried,  and 
redissolved  in  ammonia.  The  ammoniacal  solution  is  then 
slowly  evaporated,  when  if  present  crystals  of  cystin  will 
be  deposited.  The  crystals  are  hexagonal,  though  a  few 
may  be  rhombohedral,  forming  laminated  groups.      They 


Fig.  13.— Cystin. 

have  a  pale  lemon  colour  turning  greenish  on  exposure  to 
light  and  air.  The  crystals  dissolve  in  caustic  alkahes, 
and  in  strong  nitric  acid,  but  the  alkaline  carbonates  pre- 
cipitate it  from  its  acid,  and  acetic  acid  from  its  alkaline 
solutions.  Owing  to  the  x^resence  of  sulphur  in  its  consti- 
tution, a  black  precipitate  of  lead  sulphide  is  formed,  if 
cystin  is  present,  when  the  urine  is  boiled  with  caustic 
potash  and  lead  acetate,  this  is  a  very  delicate  test  for  its 
presence.  Deposits  of  cystin  may  be  mistaken  for  urates, 
but  cystin  does  not  yield  the  murexide  reaction,  and  does 
not  readily  dissolve  when  the  urine  is  heated. 

The  clinical  and  pathological  significance  of  cystinuria 
will  be  discussed  in  the  section  on  Stone  and  Gravel. 

37.  Xanthin,  C5H4N4O2.  — Xanthin  is  the  constituent  of 
an  extremely  rare  form  of  calculus,  it  has  also  been  met  as 


X  AN  THIN.  133 

gravel,  the  subjects  have  been  always  youths.  To  obtain 
it  from  a  calculus,  the  povt^der  is  dissolved  in  dilute  hydro- 
chloric acid,  and  the  solution  evaporated  when  hexagonal 
and  prismatic  crystals  of  xanthin  will  deposit,  (fig.  14,  a). 


a  b 

Fig.  14  —Xanthin. 

When  deposited  from  urine  spontaneously  as  gravel,  it  oc- 
curs in  white  scales,  or  lemon  shaped  plates,  (fig.  14, 6),  these 
dissolved  in  dilute  hydrochloric  acid  will  separate  out  in 
hexagonal  crystals,  on  evaporation  of  the  acid  solution. 
Xanthin  is  insoluble  in  water,  alcohol,  or  ether.  Soluble 
in  dilute  hydrochloric  and  nitric  acids.  Dissolved  in  a  ht- 
tle  strong  nitric  acid,  it  leaves  a  yellow  residue  on  eva- 
poration, which  when  touched  with  liquor  potassse,  and 
then  warmed  yields  a  dark  purple  colour.  This  reaction 
distinguishes  it  from  uric  acid,  which  gives  a  pink  residue 
on  evaporation  with  nitric  acid,  which  on  touching  with 
ammonia  gives  a  purple  reaction,  but  not  with  liquor 
potassse. 

The  clinical  and  pathological  significance  of  xanthin 
will  be  discussed  in  the  section  on  Stone  and  Gravel. 

Hypo-xanthin  or  sarcine  has  been  found  in  the  urine  of 
leucsemic  patients  associated  with  traces  of  xanthin,  and 
excess  of  uric  acid.  The  process  for  separating  it  is  long 
and  complicated,  and  as  its  separation  is  of  Httle  practical 
value,  the  account  of  it  will  not  be  given  here.  The  stu- 
dent will  find  it  given  in  Clinical  Chemistry,  p.  168. 


134  DISEASES    OF    THE    KIDNEY. 


Deposits  derived  from  the  Urinary  Passages. 

38.  Mucus. — The  mucus  derived  from  the  mucous 
membrane  under  the  ordinary  conditions  of  health  consists 
of  mucus  corpuscles,  or  young  epithehal  cells,  nucleated 
epithelial  cells  of  the  bladder,  and  in  women  of  the  vagina, 
with  some  amorphous  pigmentary  particles.  This  mucus 
when  the  urine  is  left  at  rest,  separates  as  a  light  transparent 
cloud,  which  is  diffused  through  the  lower  stratum  of 
the  secretion.  In  diseased  conditions  of  the  mucous 
membrane,  the  quantity  of  epithehum  discharged  may  be 
enormous,  and  is  often  mixed  with  other  morbid  products 
such  as  pus,  blood,  etc. 

Pure  mucus  forms  a  clear  translucent  mass,  in  which 
are  observed  mucus  corpuscles,  or  young  epithehal  cells, 
and  is  derived  from  all  parts  of  the  genito- urinary 
tract.  Mucus  treated  with  acetic  acid  deposits  mucin 
in  stringy  filaments.  Mucin  is  not  soluble  in  solu- 
tions of  the  alkaline  salts,  but  dissolves  in  the  caustic 
alkalies.  It  is  freely  soluble  in  hme  or  baryta  water.  It 
is  not  precipitated  from  its  solutions  by  heat.  Whilst 
only  a  slight  turbidity  is  given  with  mercuric  chloride. 
Its  solutions  are  precipitated  by  acetic  acid,  citric  acid, 
picric  acid,  alcohol,  alum,  basic  lead  acetate,  and  dilute 
mineral  acids.  In  the  case  of  these  last,  the  precipitate  is 
soluble  in  excess.  It  may  be  distinguished  from  albumin 
by  its  solutions  not  being  coagulated  when  heated,  and  by 
being  precipitated  by  acetic  acid,  and  from  pyin  by  giving 
no  precipitate  with  mercuric  chloride.  Mucin  when  boiled 
for  some  time  with  dilute  mineral  acids,  yields  acid  albu- 
min and  another  body  which  closely  resembles  dextrose,  by 
reducing  alkaline  solutions  of  cupric  sulphate.  Eichwald 
has  also  obtained  from  mucin  a  peptone  body ;  by  long 


MUCUS. 


135 


boiling  with  excess  of  lime  water,  passing  a  current  of 
-carbonic  acid  through  the  solution,  removing  the  precipi- 
tate and  evaporating  the  filtrate,  and  precipitating  it  with 
alcohol.  These  decompositions  should  be  borne  in  mind 
since  it  is  not  impossible  they  may  take  place  in  the 
urinary  passages  under  abnormal  conditions,  if  this  should 
prove  to  be  the  case,  we  should  have  an  explanation  that 
would  account  for  some  of  the  anomalous  reactions  we 
sometimes  meet  with  in  urines,  in  which  traces  of  glucose 
and  peptones  are  present,  without  our  being  able  to  assign 
any  sufficient  clinical  reason  for  their  appearance.  In 
highly  acid  urines,  if  mucin  is  in  excess,  it  will  appear  in 
fine  threads  or  strings. 

The  amount  of  mucus  is  always  increased  in  catarrhal 
and  inflammatory  conditions  of  the  urinary  passages,  and 
the  portion  of  the  tract  affected  is  generally  indicated  by 
the  character  of  the  epithelium,  thus  : — 

Round  Epithelium — rounded  and  spheroidal  cells  with  well 
defined  single  nucleus,  which  does  not  require  the  action 
-of  acetic  acid  to  render  it  visible,  are  derived  from  the 
urinary  tubules  chiefly  from  the  convoluted  portion.  It 
is  found  in  urine  associated  with  renal  casts,  both  attached 
to  them  (epithelial  casts)  or  separate.  In  the  early  stages 
-of  acute  nephritis  many  perfect  cells  will  be  observed,  but  as 
the  disease  advances  the  distinctive  characters  become  obs- 
•cured.  Many  undergo  fatty  degeneration  and  form  fatty 
•corpuscles,  which  adhering  to  the  casts  make  the  granular 
•cast,  some  become  withered  and  atrophied  whilst  others 
break  up  into  amorphous  granular  debris.  In  some  in- 
stances the  nucleus  divides  so  that  the  cell  has  the  ap- 
pearance of  having  multiple  nuclei,  and  so  be  taken  for  a 
pus  corpuscle,  it  may  be  distinguished  from  that,  however, 
by  the  fact  that  it  does  not  require  the  addition  of  acetic 
•acid  to  render  the  multiple  nuclei  visible. 


136 


DISEASES    OF    THE    KIDNEY. 


Columnar  Ejnthelium  is  derived  chiefly  from  the  pelvis- 
of  the  kidney,  the  ureters  and  the  urethra.  The  cells  are 
somewhat  triangular  but  very  irregularly  shaped,  being- 
caudate,  spindle  and  cylindrical,  with  well  defined  nuclei. 
They  often  adhere  closely  together.  They  greatly  resem- 
ble cancer  cells  when  swollen,  especially  in  alkaline  urine 
when  they  become  much  swollen,  but  they  are  by  no 
means  so  large,  perfect  or  numerous  as  cancer  cells  gene- 
rally are.  The  part  of  the  urinary  tract  they  are  derived 
from  can  only  be  determined  by  the  clinical  indications. 
If  there  is  evidence  of  pyelitis  they  are  derived  from  the 
pelvis  of  the  kidney  and  ureter,  if  there  is  gonorrhoea  from 
the  urethra,  if  associated  with  small  cylindrical  plugs  of 
mucus,  and  there  is  no  gonorrhoea,  they  are  derived  from 
the  lower  part  of  the  urethra  and  indicate  irritation  of  the- 
prostate. 


Fig.  15. — a.  Vaginal  epithelium,     c.  Eenal  Epithelium,  healthy  and  fatty.. 
h.  Epithelium  from  the  bladder,  ureter  and  pelvis  of  the  kidney. 


Squamous  Epithelium  is  derived  from  the  bladder,  and. 
also  in  females  from  the  vagina.  The  cells  are  large  and 
rounded,  considerably  larger  than  renal  cells,  and  gene- 
rally have  an  irregular  outline.  It  is  always  found  in 
normal  urine,  and  in  females  owing  to  the  admixture  of 
vaginal  mucus  is  generally  abundant.      It  is  difficult  to- 


MUCUS.  13T 

distinguish  between  the  epithehum  derived  from  the  blad- 
der and  that  coming  from  the  vagina,  as  a  rule,  however,. 
vesical  epithelium  is  smaller  than  vaginal. 

Mucus  Corpuscles,  small  oval  cells  of  greyish  colour 
rather  larger  than  a  blood  corpuscle,  generally  sur- 
rounded by  strings  of  mucus.  On  the  addition  of  water- 
or  dilute  acetic  acid  they  swell  up,  become  paler,, 
and  their  nuclei  are  rendered  more  distinct.  Caustic 
alkalies  convert  them  into  a  gelatinous  mass.  Mucus 
corpuscles  are  young  epithelial  cells,  which  are  discharged 
before  the  full  period  of  development  is  reached,  they  can- 
not be  distinguished  from  the  pus  corpuscle,  except  per- 
haps that  a  single  nucleus  is  more  generally  observed  than 
with  the  pus  corpuscle.  Tyson  (ojc*.  cit.,  p.  152),  puts  the 
relationship  of  the  two  very  clearly  when  he  says,  "  the  pus 
corpuscle  is  a  cell  too  rapidly  produced  to  develop  into- 
normal  tissue,  whilst  the  mucus  corpuscle  is  only  acci- 
dentally arrested  in  its  development. 

Pigment  Particles  have  been  well  described  by  Eoberts, 
They  are  small  celloids  less  than  the  size  of  a  blood  cor- 
puscle, stained  generally  a  reddish-orange.  Sometimes- 
the  staining  is  complete,  more  usually  dotted  through  thfr 
celloid.  No  pathological  significance  is  attached  to  them. 
Dr.  Eichardson  of  Philadelphia  has  ingeniously  suggested 
that  they  are  produced  by  little  scratches  in  the  glass  slide 
which  have  become  filled  with  oxide  of  iron  used  in  pol- 
ishing the  glass.  This,  however,  does  not  account  for  the 
fact  that  they  are  undoubtedly  more  numerous  in  cases  of 
Bright's  disease,  pyelitis,  etc.,  than  in  normal  urines. 
My  own  idea  is  that  they  are  deposited  particles  of  urobilin 
entangled  in  mucus,  the  greater  the  discharged  mucus  the 
more  numerous  will  be  the  particles  observed. 

All  forms  of  urinary  epithelium  are  distinguished  from 
mucus  and  pus  corpuscles  by  the  fact  that  dilute  acetic 
acid  is  not  required  to  render  the  nucleus  visible. 


138  DISEASES    OF    THE    KIDNEY. 

39.  Pus. — Pus  consists  of  a  liquid  portion  or  liquor 
puris,  and  pus  corpuscles.  The  liquor  puris  which  is  exuded 
liquor  sanguinis  contains  a  variable  quantity  of  albumin- 
ous constituents,  fatty  matters  and  extractives.  The 
proteid  elements,  amounting  in  laudable  pus  to  8*5  per 
cent.,  are  serum  albumin,  para -globulin  and  traces  of  a 
peptone  body.  The  fatty  matters  consist  of  neutral  fats, 
cholesterin  and  lecithin.  The  extractives  contain  glucose, 
traces  of  urea  and  leucin.  The  pus  corpuscles  cannot  be 
distinguished  from  the  mucus  corpuscles  described  above. 
These  corpuscles  are   dissolved  by   caustic   alkalies,   and 


®@    ® 

Fig.  16. — Pus-cells  in  urine,  unaltered,  and  affected  by  acetic  acid. 

this  furnishes  a  ready  test  for  pus  in  solution,  since  by 
the  addition  of  liquor  potasste  to  the  deposit  in  urine, 
consisting  of  pus,  it  is  converted  into  a  viscid  glairy  mass 
like  white  of  egg. 

Irritation  of  any  part  of  the  genito- urinary  tract  will 
furnish  pus,  and  it  is  extraordinary  what  a  slight  disturb- 
ance is  sufficient  to  cause  its  formation,  especially  in 
middle  aged  and  elderly  persons.  Exposure  to  cold,  the 
;passage  of  urine  loaded  with  urates,  oxalates  or  phos- 
jphates,  will  cause  the  presence  of  pus  cells  in  the  urine,  even 
the  use  of  highly  seasoned  dishes  will  often  induce  a  catarrh 
of  the  mucous  membrane,  in  feeble  and  dehcate  persons, 
of  sufficient  intensity  to  lead  to  the  formation  of  pus  cor- 
puscles. In  the  recent  discussion  on  the  presence  of  traces 
■of  albumin  in  the  urine  under  apparently  normal  condi- 


PUS.  139 

tious,  tliis  possible  source  of  albumin  Las  been  strangely 
overlooked,  and  Sir  Andrew  Clarke  did  good  service  at  the 
last  meeting  of  the  British  Medical  Association,  in  drawing 
attention  to  the  numerous  extra-renal  sources  of  albu- 
minuria. It  is,  however,  an  undoubted  fact,  that  a  catarrh 
■of  the  urinary,  passages  so  slight  as  to  give  rise  to  no  symp- 
toms, does  frequently  exist,  sufficient  to  give  rise  to  traces 
of  albumin  in  the  urine,  and  which  can  be  only  detected 
with  delicate  reagents.  This  Habihty  of  the  mucous 
membrane  to  secrete  pus  on  the  excitation  of  a  shght 
catarrh,  is  increased  if  any  portion  of  the  tract  has  been 
previously  subject  to  acute  inflammation,  so  that  those 
who  have  suffered  from  gonorrhoea,  gleet,  or  inflam- 
mation of  the  bladder  are  particularly  sensitive  to  the 
action  of  any  m-itant  applied  to  the  surface.  The  iirine  of 
gouty  persons  is  frequently  purulent.  Vkchow  has  re- 
cently related  how  in  his  own  case  during  an  attack  of 
.gout  his  urine  became  albuminous  and  on  examination 
was  found  to  contain  pus,  with  an  abundant  deposit  of  uric 
acid  crystals.  In  these  cases  sometimes  the  whole  urinary 
tract  seems  to  be  affected. 

When  the  pus  comes  from  the  kidney  it  may  be  derived 
from  an  abscess  of  that  organ,  or  from  inflammation  of 
the  mucous  membrane  of  the  pelvis  (pyelitis).  In  these 
cases,  as  a  general  rule,  the  urine  does  not  contain  much 
mucus  and  retains  its  acid  reaction.  It  often  comes  in 
sudden  discharges,  this  is  caused  no  doubt  by  its  passage 
•down  the  ureter  being  obstructed  by  a  coagulum,  so  that 
the  purulent  urine  collects  in  the  pelvis  till  by  its  pressure 
it  overcomes  the  resistance  to  its  discharge.  When  the 
pus  is  derived  from  the  bladder  it  is  generally  mixed  with 
a  quantity  of  mucus  (muco-pus),  and  the  urine  readily 
undergoing  fermentation  becomes  ammoniacal.  In  con- 
sequence of  this  the  reaction  becomes  alkalme,  and  the 


140  DISEASES    OF    THE    KIDNEY. 

piis  is  converted  into  stringy  viscid  masses,  loaded  with, 
ammonio-magnesium  phosphate  in  sujEficient  quantity 
as  frequently  to  prevent  or  obstruct  the  flow  of  urine. 
Pus  too  may  find  its  way  into  the  urinary  tract  from 
without,  as  when  abscess  results  from  inflammation  of  the 
cellular  tissue  around  the  kidney  (perinephritis),  or  at  the 
base  of  the  bladder,  or  from  i^rostatic  abscess. 

Pus  is  deposited  in  neutral  and  acid  urines  as  a  dense 
creamy  layer,  in  alkaline  urines  as  a  ropy  stringy  mass. 
To  distinguish  between  pus  and  mucus  when  both  are 
present  is  often  difficult,  the  best  plan  is  to  add  mercuric 
chloride,  which  precipitates  the  pyin,  but  not  the  mucin ; 
this  is  filtered  off,  and  the  filtrate  treated  with  acetic  acid, 
which  precipitates  the  mucin.  To  differentiate  between 
albuminuria  derived  from  the  blood  vessels,  from  the 
albumia  of  the  Hquor  puris,  is  impossible,  and  we  must 
rely  on  the  general  clinical  character  of  the  urine,  and 
whether  the  amount  of  albumin  observed  corresponds  to 
what  one  would  expect  from  the  number  of  corpuscles 
present,  or  is  in  excess  of  them. 

40.  Casts. — Various  views  have  been  expressed  regard- 
ing the  nature  and  mode  of  formation  of  the  tube  casts,  that 
appear  in  the  urine  as  the  result  of  diffused  inflammation 
of  the  kidneys.  Some  believe  them  to  be  formed  from  the 
epithelium,  either  by  a  secretion  from  these  cells,  or 
by  their  disintegration  and  fusion.  Others,  and  this  is  the 
view  generally  held  at  present,  regard  them  as  the  result 
of  an  albuminous  exudate,  poured  out  from  the  capillaries 
into  the  tubules.  This  exudate  also  saturates  the  epithe- 
lium, and  loosens  it,  and  thus  ultimately  leads  to  its 
disintegration  and  destruction.  If  the  albuminous  moulds 
formed  by  the  exudate,  come  away  before  detachment  of 
the  epithelium  takes  place,  then  we  have  the  small  hyaline 
cast  (fig.  17,  e),  if  however,  the  epithelium  is  loosened,  this 


CASTS.  141 

■will  adhere  to  the  surface  of  the  cast,  and  then  we  have 
the  epithelial  cast  (fig.  17,  h),  if  blood  should  be  effused  into 
the  tubule,  then  blood  corpuscles  adhere,  and  we  have  the 
hloocl  cast  (fig.  17,  a),  if  the  epithelium  has  undergone  de- 
generation, then  the  cast  is  covered  with  a  granular  debris, 
and  we  have  the  granular  cast  (fig.  17,  c).  As  the  disease 
advances  and  the  tubes  become  bared  of  their  epithelium 
and  widened,  the  casts   are  increased  in   breadth,  broad 


IriG.  17. — a.  Blood  casts.        b.  Epithelial  casts.         c.  Granular  casts. 
d.  Fatty  casts.        e.  Hyaline  casts. 

hyaline  cast  (fig.  17,  e),  these  are  often  dotted  with 
oil  drops,  the  result  of  fatty  degeneration  of  the  renal 
cells,  fatty  cast  (fig.  17,  d).  The  hyaline  casts  often 
undergo  a  waxy  degeneration,  and  stain  deeply  with 
iodine  and  methyl- violet.  Casts  therefore  are  either 
simply  hyaline,  or  else  hyaline  material  that  has  under- 
gone degeneration,  or  to  which  epithelial  elements  have 
been  added.     Casts  vary  much  in  size,  the  small  hyaline 


142  DISEASES    OF    THE    KIDNEY. 

rarely  exceed  -025  //.,  whilst  the  broad  are  often  "05  /x,. 
in  width,  the  epithelial  and  granular  casts  are  usually 
of  medium  size  and  range  from  035  to  -04  (j..  Crystals 
of  triple  phosphate,  oxalate  of  lime,  or  uric  acid  often  ad- 
here to  tube  casts,  according  to  the  prevailing  reaction  of 
the  urine. 

The  presence  of  casts  in  urine  may  be  overlooked  unless 
care  is  taken.  As  they  subside  slowly,  especially  in  urines 
of  low  specific  gravity,  time  should  he  allowed  for  that 
purpose.  The  surest  way  is  to  place  the  urine  in  a  urine 
glass,  such  as  made  for  me  by  Krohne  and  Sesemann,, 
which  is  a  conical  sha]3ed  vessel,  with  the  lower  end  drawn 
out  into  a  fine  tube,  like  that  of  Mohr's  burette,  and  fitted 
with  an  india-rubber  tube,  glass  jet  and  ]pinch-cock.  The 
urine  is  allowed  to  settle  for  twelve  hours,  and  then  a  drop' 
or  so  is  drawn  off  on  a  glass  slide  by  means  of  the  jet,  and 
examined  by  the  microscope.  This  method  avoids  dis- 
turbing the  deposit  by  j^lunging  a  i^ipette  into  the  urine, 
for  so  light  are  these  objects,  that  the  currents  caused  by 
the  downward  movement  of  the  pipette  through  the  fluid 
may  carry  them  away  from  its  nozzle,  and  so  if  they  are 
scanty  none  may  be  taken  up.  In  urines  of  very  low 
specific  gravity,  if  no  casts  are  withdrawn  at  the  end  of 
twelve  hours,  it  is  advisable  to  sprinkle  a  very  fine  light 
powder  on  the  surface  of  the  urine.  This  by  sinking- 
slowly  through  the  urine  will  carry  any  floating  casts, 
downwards  with  it. 

Casts  are  never  found  in  normal  urine,  nor  is  it  pro- 
bable that  they  ever  occur  except  in  association  with 
nephritis.  The  instances  in  which  they  are  found  in 
jaundice,  or  when  a  renal  calculus  exists,  or  in  dyspep- 
sia associated  with  oxaluria,  etc.,  is  no  evidence  to- 
the  contrary,  since  the  presence  of  these  abnormal  pro- 
ducts in  the  urine  may  readilv  excite  a  degree  of  nephritis- 


CASTS.  14S 

sufificient  to  determine  an  exudate  from  the  vessels  sur- 
rounding the  tubules.  Tyson  {op.  cit.,  p.  168)  says, 
while  it  is  not  impossible  for  non-albuminoiis  urine  to 
contain  casts,  he  has  never  met  them,  except  in  a  few  in- 
stances, and  in  these  albumin  had  been  already  present, 
the  albumin  having  disappeared  before  the  last  casts  had 
been  washed  out.  Casts  are  not  met  with  in  cases  of 
purely  functional  albuminuria,  whenever  in  such  a  case 
after  albumin  has  been  sometime  observed,  casts  make 
their  appearance,  we  may  be  sure  that  organic  changes  are 
also  taking  place.  Although  the  presence  of  casts  may 
be  taken  as  confirmatory  of  acute  or  chronic  nephritis, 
the  fact  of  not  finding  them  on  one  examination  must  not 
allow  us  to  assume  the  contrary,  since  they  are  sometimes 
retained  for  a  short  while,  or  else  passed  in  such  scanty 
numbers  as  to  be  overlooked.  Eepeated  examinations 
should  therefore  be  made,  when  if  any  changes  have  oc- 
curred in  the  tubules  they  are  sure  to  be  discovered.  Fine 
hyaline,  epithelial  and  blood  casts  are  met  with  in  acute 
cases  of  recent  origin.  Broad  hyaline,  granular,  waxy, 
and  fatty  casts  indicate  that  the  nephritis  has  passed  from 
the  acute  to  the  chronic  stage ;  in  the  later  stages  the 
granular  cast  disappears  and  the  casts  are  altogether 
hyaline  and  fatty.  It  is  doubtful  whether  casts  are  sepa- 
rated from  the  tubules  in  lardaceous  degeneration  of  the 
kidneys,  but  as  this  process  seldom,  if  ever,  occurs  with- 
out nephritis  concurrently  taking  place,  it  is  difficult 
to  say  in  any  given  case  whether  the  few  hyaline  casts 
generally  observed  in  these  cases  are  not  due  to  this 
cause. 

In  addition  to  these  casts  simple  aggregations  of  epithe- 
lial cells  and  fine  plugs  of  mucus  may  be  met  with  in  the 
urine,  forming  fine  cylinders.  These  mucus  plugs  form 
elongated  fibrils  often   branched.      In   many  cases  they 


144  DISEASES    OF    THE    KIDNEY. 

seem  to  be  formed  by  an  bigbly  acid  condition  of  the 
urine  precipitating  the  mucin,  they  are  dissolved  by 
liquor  potassae ;  they  are  more  frequently  met  with  in 
disease  of  the  bladder  t]:an  in  renal  disease.  Pus  casts 
are  occasionally  observed,  they  are  generally  found  in  the 
urinary  tubules  and  in  the  urine  in  cases  of  disseminated 
suppuration  of  the  kidney.  As  minute  cylinders,  mucous 
plugs  in  which  are  embedded  amorphous  granules  and 
minute  acicular  crystals  of  phosphate  of  lime  may  be  ob- 
served in  most  cases  of  vesical  and  prostatic  disease.  In  the 
urine  from  a  case  of  locomotor  ataxy  they  constituted,  with 
the  exception  of  a  mere  trace  of  albumin,  the  only  morbid 
phenomenon.  The  addition  of  liquor  potassffi  dissolved  the 
purulent  matrix  leaving  the  phosphate  of  lime  unaltered. 
Tubercular  masses  are  found  in  the  urine  of  persons 
suffering  from  scrofulous  disease  of  kidneys  or  bladder. 

41.  Fatty  Matters. — The  urine  normally  contains  a 
trace  of  fatty  matter  but  so  minute  that  over  six  pints 
yields  but  H  grain  (Schunk).  It  is  apparently  a  neutral 
fat  composed  of  palmitin  and  stearin.  When  animals  are 
fed  upon  excess  of  fatty  articles,  glycerin-phosphoric  acid, 
according  to  Zuelzer  (op.  cit.,  p.  18),  is  found  in  the  urine, 
derived  from  some  phosphorized  fatty  body,  probably 
lecithin.  It  is  also  probable  that  the  neutral  fats  are  in- 
creased by  a  fatty  diet,  since  oil  globules  have  been 
detected  in  the  urine  of  persons  taking  large  amounts  of 
•cod-liver  oil.  In  pathological  conditions,  fatty  matters 
consisting  of  neutral  fats,  cholesterin  and  lecithin  can  be 
extracted  from  urine  by  means  of  ether.  So  also  in 
chronic  Bright' s  disease  when  the  epitheUum  is  undergo- 
ing fatty  degeneration.  In  acute  yellow  atrophy  of  the 
liver,  when  the  renal  cells  undergo  acute  fatty  changes,  the 
urine  contains  an  excess  of  fatty  matter.  In  the  urine  of 
a  patient,  who  died  of  acute  diabetic  coma,  I  found  an 


FATTY   MATTERS.  145 

abundance  of  oil  globules.  In  chyluria,  the  urine  contains 
a  considerable  amount  of  fatty  matter  whicli  yields  neutral 
fats,  cholesterin  and  lecithin.  As  an  urinary  deposit,  plates 
of  cholesterin  are  sometimes  met  with,  in  these  cases  the 
cholesterin  is  not  derived  directly  from  the  blood,  but  from 
old  purulent  collections  of  which  the  more  soluble  portions 
have  undergone  absorption.  Leucin  and  cholesterin  are 
sometimes  mistaken  for  each  other,  the  former,  however, 
is  insoluble,  the  latter  freely  soluble  in  ether.  Fatty  con- 
cretions (urostealith),  consisting  of  a  mixture  of  fatty  and 
soapy  matters  mixed  with  mucus  and  withered  cell  forms, 
are  sometimes  formed  in  the  urinary  passages,  these  also 
point  to  some  past  purulent  formation  which  has  under- 
gone concretion. 

To  separate  the  fatty  matters  from  the  urine  and  to  ob- 
tain them  in  their  separate  forms,  100  c.c.  of  the  twenty- 
four  hours'  urine  must  be  evaporated  to  near  dryness  and 
the  residue  exhausted  with  ether.  This  is  best  done  by 
boiling  the  etherial  mixture  in  Drechsel's  apparatas  if  at 
hand,  or  in  a  glass  flask  fitted  with  a  long  glass-tube 
twenty  inches  long,  in  this  case  the  heat  is  best  apphed  by 
keeping  the  flask  in  nearly  boiling  water  and  adding  more 
ether  to  supply  the  loss  by  evaporation.  After  some  hours 
the  etherial  solution  is  poured  off  and  evaporated  to  dry- 
ness on  a  weighed  platinum  capsule,  this  gives  the  weight 
of  the  neutral  fats,  the  cholesterin,  and  lecithin.  To 
separate  these,  dissolve  the  residue  in  boiling  alcohol  and 
add  baryta  water,  boil  the  mixture  till  the  whole  of  the  al- 
cohol is  expelled,  filter  whilst  hot.  The  filtrate  contains  the 
neutral  fats  in  the  form  of  baryta  soap ;  the  precipitate 
consists  of  cholesterin  and  the  products  of  the  decomposi- 
tion of  lecithin,  viz.,  neurin  and  glycerin-phosphoric  acid. 
The  precipitate  is  then  mixed  with  water  and  treated  with 
absolute  ether,  which  removes  the  cholesterin ;  the  etherial 

L 


146  DISEASES    OF    THE    KIDNEY. 

solution  is  tlien  poured  off  and  evaporated ;  the  residue 
dissolved  in  boiling  alcohol  evaporated  and  the  crystallised 
cholesterin  weighed.  The  watery  mixture  left  after  the 
removal  of  the  ether  is  evaporated  to  dryness  and  the 
residue  fused  with  sodium  hydrate  and  nitre,  the  mass  is 
then  dissolved  in  water  and  nitric  acid  added.  "With  this 
solution  ammonium  molybdate  gives  a  yellow  precipitate. 
Collect  this  precipitate,  and  dissolve  it  in  ammonia.  To 
this  ammoniacal  solution  add  a  solution  of  magnesia,  col- 
lect, wash,  dry  and  ignite  this  precipitate,  and  then  weigh. 
100  parts  of  this  magnesium  pju'ophosphate  is  equivalent 
to  764  5  parts  of  lecithin.  To  make  the  calculation, 
suppose  we  are  examining  the  urine  of  a  case  of  chyluria, 
and  have  found  by  the  initial  step,  the  weight  of  the  total 
fatty  matters,  the  neutral  fats,  the  cholesterin  and  the 
lecithin,  .and  for  example  sake  we  say  they  amount  to 
0*85  grm.  in  100  c.c.  of  urine.  The  second  stex?  gives  us 
the  amoitnt  of  cholesterin,  which  on  weighing  is  found 
to  be  say  '09  grm.  Whilst  the  third  step,  by  calculation 
of  the  weight  of  the  pyrophosphate,  has  told  us  the  amount 
of  lecithin,  and  which  we  will  say  amounts  to  0'42  grm. 
Now  if  we  deduct  the  ascertained  weight  of  the  cholesterin 
and  lecithin  from  the  total  fatty  matters  the  difference 
will  represent  the  weight  of  the  neutral  or  saponifiable 
fats.  Thus,  0-85- (-09 +  -42) =0-34  grm.,  so  that  the 
percentage  composition  of  the  fatty  matters  of  this  case 
of  chyluria  reads  thus,  neutral  fats  0"34  gi'm.,  cholesterin 
0*09  grm.,  lecithin  0-42  grm. 

42.  Cholesterin,  C26H44O.— Cholesterin  is  a  white  cry- 
stalline substance,  resembling  spermaceti.  It  is  deposited 
from  its  alcoholic  solution  in  the  form  of  glistening  rhom- 
bic i^lates  having  notched  edges ;  hghter  than  water, 
very  soluble  in  ether,  insoluble  in  water  or  cold  alcohol. 
Touched  with  a  drop  of  strong  nitric  acid  and  gently  eva- 


FUNGI   AND    PARASITES.  147 

porated,  cholesterin  gives  a  yellow  colour  'which  turns  red 
on  the  addition  of  a  drop  of  ammonia.  A  mixture  of  two 
parts  of  strong  hydrochloric  acid,  and  one  part  of  ferric 
chloride  shghtly  diluted,  evaporated  with  cholesterin  gives 
a  violet  coloured  residue.  The  conditions  under  which 
cholesterin  is  sometimes  deposited  in  urine  and  the  manner 
of  separating  it  is  described  in  the  preceding  paragraph. 

43.  Fungi  and  Parasites. — Penicillium  Glaucum.  Mil- 
dew developes  in  acid  urine,  and  dies  in  alkaline  urine.  The 
sporules  are  oval,  nucleated,  vary  greatly  in  size.  Accord- 
ing to  recent  experiments  these  sporules,  removed,  washed 
and  dried  at  55°  C,  on  again  being  moistened  will  revive 
and  then  decompose  dilute  solutions  of  urea.  The  thallus 
is  derived  from  sporules  either  by  elongation  or  budding, 
and  then  .forms  an  elongated,  branched,  cellular  shoot, 
which  rises  to  the  surface  of  the  urine  and  gives  off 
branched  tufts  of  sporules.  It  is  always  abundant  in 
albuminous  urine,  and  in  urines  containing  mudh  mucus. 
Kiesteine,  a  greasy  looking  pellicle,  which  forms  on  the  sur- 
face of  the  urine  of  pregnant  women,  when  kept  a  few  days, 
consists  of  this  fungus,  mixed  with  fatty  matter,  and 
withered  cell  forms.  The  fatty  matter  is  probably  derived 
from  the  fatty  degeneration  of  the  epithelial  cells,  which 
are  abundantly  shed  from  the  vagina  and  bladder  in  this 
condition. 

Torula  cerevisice:  Sugar  fungus  resembles  in  its  early 
growth  that  of  the  penicillium,  but  the  thallus  is  distinct, 
having  a  round  clustered  head  covered  with  a  brownish 
powder.  It  is  pecuHar  to  saccharine  urine.  An  excellent 
account  of  the  development  of  these  growths  is  given  by 
Hassall  {Med.  Chir.  Trans.,  vol.  xxxvi,,  p.  32). 

Sarcince  have  been  frequently  found  in  urine,  they 
have  been  met  with  in  the  pelvis  of  the  kidney,  but  their 
chief  seat  is   probably  the   bladder.      They  present  the 

l2 


148  DISEASES    OF    THE    KIDNEY. 

characteristic  wool-pack  appearance,  viz.,  cubical  masses 
with  transverse  divisions,  they  are  smaller,  however,  than 
those  met  with  in  the  stomach  or  lung.  They  exist  both 
in  acid  and  alkaline  urine.  Their  presence  in  urine  is  al- 
ways associated  with  more  or  less  lumbar  pain,  frequent, 
micturition  and  abundant  mucus  deposit. 

Bacteria.  Dr.  Eoberts  has  described  some  interesting 
cases  of  bacteruria,  occurring  without  decomposition  of  the 
urine.  The  organisms  appear  to  be  of  one  or  more  kinds.. 
Some  appear  to  resemble  bacillus  subtilis,  and  they 
mostly  appear  as  short  rods  or  filaments.  They  cause  nO' 
decomposition  in  the  urine,  which  keeps  its  acidity  for 
some  days.  The  patients  complain  of  frequent  and  pain- 
ful micturition  and  pains  about  neck  of  the  bladder,  there- 
may  be  no  manifest  disease  of  the  urinary  organs.  He 
has  also  met  with  micrococci  chains  in  the  freshly  passed 
urine  from  a  patient  who  had  resided  in  South  America,, 
although  he  has  repeatedly  made  examinations,  he  has 
failed  to  observe  the  same  condition  in  any  other  case,  he 
therefore  thinks  it  probable  that  this  latter  is  of  exotic 
origin. 

Stale  decomposing  urine  speedily  developes  a  number 
of  small  moving  organisms,  bacteria  termo,  and  ammoniacal 
urine  always  contains  the  spherical  bacterium,  micrococcus- 
iirecB,  which  causes  ammoniacal  decomposition. 

Spermatozoa.  Although  spermatozoa  can  hardly  be  re- 
garded as  parasites  it  is  convenient  to  consider  them  here.. 
They  consist  of  a  club-shaped  oval  head  and  a  fine  whip- 
like  tail.  Their  length  is  about  g^^  inch.  In  urine  they 
lose  the  vibratile  movement  observed  in  semen.  The  dis- 
cussion of  spermatorrhoea  does  not  fall  within  the  limits 
of  this  work  except  with  regard  to  its  occasional  rela- 
tionship with  oxaluria  where  a  few  words  will  be  said  about, 
it. 


EXTEANEOUS   MATTERS.  149 

Entozoa.  The  following  are  the  chief : — Echinococcus 
honiinis  or  hydatid  cyst,  the  hooklets  of  which  may  be 
found  in  the  urine.  Strongylus  gigas,  a  nematoid  worm, 
said  to  be  occasionally  found  in  the  kidney.  Bilharzia  hmna- 
tobia,  a  trematode  worm,  chiefly  affecting  the  bladder  and 
intestines,  the  ova  of  which  are  found  in  the  urine.  This 
parasite  gives  rise  to  the  endemic  hematuria  of  tropical 
climates,  it  has  been  especially  observed  in  Egypt,  the  Cape 
and  Mauritius.  Pentastoma  denticulatum,  a  minute  para- 
site that  has  been  found  on  one  occasion  in  the  kidney 
Filaria  sanguinis  liominis  has  been  found  in  the  urine  of 
patients  suffering  from  chyluria.  A  detailed  account  of 
these  parasites  will  be  found  in  the  chapter  on  Parasites 
of  the  Kidney.  In  addition  to  these  parasites,  thread- 
worms, ascaricles,  round- worms,  lumbrici,  joints  of  tape- 
worms, tcenia,  may  be  discharged  by  the  bowel  into  the 
urine.  Moreover,  the  parasites  of  other  animals  may 
accidentally,  or  intentionally,  find  their  way  to  the  cham- 
ber vessel. 

44.  Extraneous  matters. — Hair,  foetal  bones,  faeces, 
■etc.,  may  find  their  way  into  the  urine  from  com- 
munication with  cysts,  or  intestines,  with  the  urinary 
passages.  Fibres  of  linen  from  the  cloths  used  in 
cleaning  the  chamber  utensils,  fragments  of  human  or 
animal  hairs,  dust  and  debris  of  every  kind  and  descrip- 
tion, and  which  are  only  to  be  recognised  by  their 
microscopic  appearance,  a  full  description  of  which 
will  be  found  in  works  especially  devoted  to  the  repre- 
sentation of  microscopic  objects.  The  student,  how- 
ever, who  has  made  himself  thoroughly  acquainted  with 
the  chemical  reactions  and  microscopic  appearance  of  true 
urinary  deposits,  can  never  be  misled  by  the  presence  of 
these  extraneous  and  accidental  matters.  "When,  however, 
.substances  are  introduced  intentionally  for  the  purpose  of 


150  DISEASES    OF    THE    KIDNEY. 

deception,  the  fraud  is  sometimes  difficult  of  detection. 
Thus,  a  short  while  since,  I  received  a  fragment  of  grit 
said  to  have  come  from  the  urinary  passages.  It  charred 
under  the  blow-pipe  flame,  decrepitating  with  great  vio- 
lence, and  the  ash  effervesced  on  the  addition  of  dilute 
acid ;  it  therefore  closely  resembled  oxalate  of  lime.  There 
was  however,  an  insoluble  residue,  that  resisted  all  chemi- 
cal reagents,  and  was  not  reduced  by  the  blow-pipe  ;  the 
quantity  at  my  command  being  small,  I  could  not  decide 
its  nature.  I  then  wrote  to  ask  if  more  of  the  deposit 
could  be  obtained,  and  then  I  found  that  the  insoluble  re- 
sidue consisted  of  sand.  I  therefore  concluded  that  the 
deposit  consisted  of  mortar,  the  organic  matters  which 
charred,  being  probably  the  hairy  substances,  which  are 
mixed  with  good  mortar  to  render  it  more  binding,  and 
perhaps  some  of  the  mucus  from  the  urine  in  which  it  had 
been  immersed.  Cane  sugar  is  not  infrequently  added  to 
urine  by  hysterical  patients,  but  this  fraud  is  easily  de- 
tected, more  difficult  is  the  diagnosis  in  the  case  of  the 
addition  of  egg  albumin,  honey  or  blood.  In  these  cases 
however,  there  is  generally  some  important  link  wanting 
in  the  clinical  evidence,  which  leads  to  detection,  as  soon 
as  suspicion  is  aroused  as  to  the  patient's  bona  fides. 


Organic  Deposits  separated  from  the  Urine. 

45.  Organized  Deposits. — In  addition  to  the  deposits- 
derived  from  the  urinary  passages  which  we  have  just  con- 
sidered, it  happens  that  substances  derived  from  the  blood,. 
and  ordinarily  held  in  suspension  in  the  urine,  are  often 
deposited.  The  causes  of  this  deposition  may  generally  be 
referred  to  either  of  the  following  conditions,  or  a  combina- 
tion of  them,     (a)  To  changes  in  the  reaction  of  the  urine„ 


ORGANIZED    DEPOSITS. 


151 


as  in  the  case  of  deposit  of  triple  phosphate  in  ammoniacal 
urine,  and  uric  acid  in  highly  acid  urines,  {b)  To  absolute 
excess,  as  in  certain  conditions  of  the  system  when  uric  acid, 
oxalate  of  lime,  or  phosphate  of  lime  is  eliminated  in  excess. 
(c)  To  relative  excess,  when  the  proportion  of  water  in  the 
urine  is  diminished,  as  when  urates  are  deposited  in  pyrexia! 
conditions,  or  after  profuse  sweating,  (d)  To  the  absolute 
insolubility  of  the  substance,  as  with  oystin,  xanthin,  or 
leucin.  As  the  chemical  nature,  and  the  clinical  signi- 
ficance of  the  substances  forming  these  deposits  are 
discussed  elsewhere,  it  is  only  necessary  to  enumerate 
them  here,  with  a  brief  reference  to  their  chief  characteris- 
tics, by  which  they  may  be  distinguished,  and  which  are 
given  in  the  following  table.  For  fuller  details  the  reader 
is  referred  to  their  respective  headings. 


Table  of  the  chief  Organized  deposits  separated  frovi  urine. 


Deposit. 

Form. 

Heat. 

Reaction 

OF    URINE. 

Liquor 
Potass.^. 

Acetic 

Acid. 

Special 
Character. 

Uric  Acid, 

Rhombic 

Very     in- 

Acid 

Soluble 

Insoluble 

Murexide  reaction. 

p.  80 

crystals. 

Variable 

forms. 

soluble   at 

all  tem- 
peratures. 

Urates, 

Amorphous 

Soluble  at 

Acid 

Soluble 

Insoluble 

Murexide  reaction. 

p.  81 

or  spiked 
globules. 

40°  C. 

Cystin, 

Hexagonal 

Insoluble 

Acid 

Soluble 

Insoluble 

Soluble     in      liquor 

p.  132 

plates. 

ammonias  but  not 
its  carbonate.  Blk. 
precip.  when  heat- 
ed with  liq.  potas- 
s£  and  acetic  acid. 

Xanthin, 

Lemon- 

Insoluble 

Acid 

Soluble 

Insoluble 

Evaporated  with  ni- 

p. 133 

shaped 
crystals. 

tric  acid  and  resi- 
due touched  with 
liq.  potassas  deep 
purple  reaction. 

152  DISEASES    OF    THE    KIDNEY. 

Table  of  the  chief  Organized  deposits,  etc.      (  Contiiined ) 


Deposit. 

Form. 

Heat. 

Reaction 

OF    URINE. 

Liquor 
PoTAssa;. 

Acetic 
Acid. 

Special 
Character. 

Calcium 
Oxalate, 

p.  8i> 

Small    octo- 
hedral     cry- 
stals.   Vari- 
able forms. 

Insoluble 

Acid  or 
Alkaline 

Insoluble 

Insoluble 

Soluble  in  acid  so- 
dium phosphate. 
Ash  etfervesces 
with  hydrochloric 
acid. 

Calcium 

Phosphate, 

p.  94 

Amorphous 
or  fine 
stellar 
crystals. 

Insoluble 

Alkaline 
(fixed) 

Insoluble; 

Soluble 

Neatral  or  faintly 
acid;  urinebecomes 
turbid  on  boiling, 
and  clears  up  on 
addition  of  acid. 

Ammonio- 

Magnesium 

Phosphate, 

p.  96 

Triangular 

prisms  or 

feathery 

crystals. 

Insoluble 

Alkaline 
(volatile) 

Insoluble 

Soluble 

Mixed  with  phos- 
phate of  lime,  the 
ash  fuses  under 
blow-pipe  into  an 
enamel-like  crust. 

Leucin 

and 
Tyrosin, 

Oily    discs. 
Acicular 

Soluble 
Soluble 

Acid  or 
Alkaline 

Soluble 
Soluble 

Insoluble 
Insoluble 

Insoluble  in  ether. 
Solutions  boiled  with 

P-  131 

needles. 

mercuric  nitrate 
give  red  precipi- 
tate. Violet  reac- 
tion with  ferric 
chloride. 

CLASSIFICATION.  163 


CHAPTER   III. 
Diffuse  Inflammation  of  the  Kidneys. 

46.  Classification. — Cotugno  was  the  first  physician 
-who  discovered  that  the  urine  of  dropsical  patients  some- 
times contained  albumin,  which  he  supposed  resulted  from 
an  altered  condition  of  the  blood  serum.  Dr.  Blackall,  of 
Exeter,  however,  was  the  earliest  observer  who  connected 
albuminuria  with  actual  disease  of  the  kidney,  a  fact 
which  Bright  a  few  years  later  worked  out  with  such  a 
■degree  of  completeness  that  his  name  has  ever  since  been 
associated  with  the  disease.  Dr.  Bright  distinguished  one 
form,  but  three  varieties,  of  diseased  kidney  as  associated 
with  albuminuria,  and  considered  that  each  variety  was 
only  a  stage  towards  the  development  of  the  complete 
form,  which  he  believed  was  reached  in  the  granular  kidney. 
He  held  that  the  whole  process  was  due  to  the  presence  of 
a  morbid  deposit  in  the  kidney,  leading  to  a  granular  con- 
dition of  the  kidney,  and  consequently  applied  the  term 
'Agranular  degeneration'"  to  the  disease  in  all  its  stages. 
The  idea,  however,  of  a  morbid  deposit  soon  gave  place  to 
more  correct  views,  which  attributed  the  changes  in  the 
kidney  to  the  process  of  inflammation.  Vu'chow,  in 
Germany,  and  George  Johnson,  in  England,  were  the  chief 
exponents  of  this  doctrine.  Virchow  insisted  on  the  im- 
portance of  distinguishing  whether  the  changes  proceeded 
from  the  epithelium  (croupous  or  parenchymatous  neph- 
ritis), or  from  the  interstitial  tissue  (cirrhosis),  or  from  the 
vessels  (waxy  degeneration).  He  clearly  taught  that 
though   these   three   different   forms   were    distinct   from 


154  DISEASES    OF    THE    KIDNEY. 

each  other,  still  that  one  form  having  lasted  a  long 
while  might  yet  end  in  being  complicated  by  one  of  the 
others,  or  by  both  of  them  together.  Thus  an  old  paren- 
chymatous, or  a  long  standing  interstitial  nephritis,  might 
have  grafted  on  it,  in  the  stage  of  marasmus,  waxy  de- 
generation ;  or  kidneys,  the  subject  of  parenchymatous 
inflammation,  might  undergo  changes  of  an  interstitial 
character.  Dr.  George  Johnson  further  extended  the  idea 
of  the  multiplicity  of  the  forms  of  Bright's  disease,  and 
classified  them  with  regard  to  the  changes  that  took  place 
in  the  renal  epithelium.  Thus  he  divided  the  disease  into 
an  acute  desquamative  nephritis,  a  chronic  non-desquama- 
tive  nephritis,  and  a  chronic  desquamative  nephritis.  He 
also  included  waxy  degeneration  as  a  form  of  Bright's  dis- 
ease. He  was  the  first,  moreover,  to  point  out  the  hyper- 
trophied  condition  of  the  small  arteries  that  occurs  in 
contracted  granular  kidneys.  In  1860,  or  eight  years  after 
the  appearance  of  Johnson's  work,  Traube  distinguished 
four  forms  of  Bright's  disease  :^1.  Circum-capsular,  which 
was  characterised  by  the  growth  of  connective  tissue  round 
the  glomeruli,  and  which  pursued  a  chronic  course  from 
the  first,  and  which  corresponds  to  the  chronic  form  of 
interstitial  nephritis ;  2.  Inter-tubular  which  was  attended 
by  a  new  growth  between  the  tubes,  and  which  began 
acutely  with  more  or  less  tendency  to  hemorrhage  ;  3.  Cir- 
rhosis produced  by  venous  congestion,  as  in  long-standing 
heart  disease  ;  and,  4.  Waxy  degeneration  of  the  kidney. 
According  to  Traube,  the  changes  that  took  place  in  the 
renal  epitheliu.m  in  both  the  circum-capsular  and  inter- 
tubular  varieties  were  secondary  to  those  occurring  in  the 
connective  tissue. 

Though  this  view  was  not  generally  accepted,  still 
Traube's  investigations  drew  attention  in  a  more  marked 
degree  to  the  importance  of  studying  the  nature  of  the 


CLASSIFICATION.  155' 

changes  occurring  in  the  connective  tissue  around  the 
glomeruli  and  between  the  tubules,  than  had  been  previ- 
ously done.  The  subject  was  closely  followed  up  in. 
England  by  Dr.  Dickinson,  and  in  Scotland  by  Dr. 
Grainger  Stewart,  and  hj  them  our  knowledge  was  still 
further  advanced,  and  the  nature  of  the  processes  made 
more  definite.  According  to  Dickinson,  whose  classifica- 
tion has  been  generally  adopted  by  the  London  schools,, 
Bright's  disease  may  be  divided  into  three  forms  :  — 1.  Tubal 
nephritis,  acute  or  chronic,  in  which  the  renal  epithelium 
and  tubes  are  primarily  affected  by  the  inflammatory  pro- 
cess, and  which  corresponds  with  acute  and  chronic  paren- 
chymatous nephritis ;  2.  Granular  degeneration  in  which 
the  inter-tubular  matrix  undergoes  contraction  ;  this  may 
be  the  result  of  the  chronic  tubal  nephritis,  but  generally 
arises  as  a  primary  condition  ;  and,  3.  Depurative  disease,  or 
in  other  words,  waxy  or  lardaceous  degeneration  of  the 
kidneys. 

Dr.  Grainger  Stewart   also  recognizes  three  forms : — 

1.  The  inflammatory,  which  passes  through  three  stages,, 
viz.,    inflammation,    fatty    degeneration,    and    atrophy; 

2.  The  cirrhotic  or  contracting  form ;  and,  3.  The  waxy 
or  lardaceous. 

According,  however,  to  more  recent  views,  the  classifica- 
tion of  Bright's  disease  has  been  further  simplified.  Waxy 
or  lardaceous  degeneration  has  been  excluded  as  a  distinct 
form,  and  is  associated  with  Bright's  disease  only  when 
grafted  on  long  continued  inflammation  of  the  kidneys. 
Similarly  the  false  cirrhosis  (cyanotic  induration)  of  the 
kidneys,  the  result  of  venous  congestion  dependent  on  long^ 
standing  disease  of  the  heart  is  now  generally  considered 
as  distinct  from  the  diffuse  inflammation,  leading  to 
granular  contracted  kidney.  Moreover,  the  doctrine  of  the 
unity  of  Bright's  disease  has  been  revived,  and  histological 


156  DISEASES    OF    THE    KIDNEY. 

investigations  have  shown  the  important  part  played  by  the 
changes  in  the  glomeruH  in  the  evolution  of  chronic  Bright' s 
disease. 

"With  regard  to  the  unity  of  Bright's  disease,  Eosenstein 
{op.  cit.)  has  stated  concisely  the  view,  which  leads  us 
to  regard  the  alterations  occurring  in  the  kidney,  as  not 
due  to  two  distinct  inflammatory  processes,  the  one  paren- 
chymatous and  the  other  interstitial,  but  to  refer  them  only 
to  a  diffused  nephritis.  Diffused  inflammation,  he  says, 
is  the  basis  of  Morbus  Brightii,  an  inflammation  which 
like  that  of  other  organs  begins  with  changes  in  the  cir- 
culation. It  is  characterized  by  the  exudation  of  lymph 
•corpuscles,  whilst  at  the  same  time  the  epithelial  elements 
■of  the  glomeruli  and  urinary  tubules  are  affected  by  the 
inflammatory  irritation.  The  kidneys,  therefore,  that 
■come  under  observation  in  Bright's  disease  always  show 
■changes  of  all  the  tissue-elements,  and  though  one  ele- 
ment may  be  more  prominent  in  its  alteration  than 
another,  we  are  not  therefore  to  speak  of  a  parenchyma- 
tous or  interstitial  nephritis,  but  only  of  a  diffused  inflam- 
mation. "  Only  more  or  less  the  preponderance  of  one 
or  more  tissue- element  determines  the  outwardly  different 
form  of  the  red  swollen,  large  white,  the  pale  granular 
•or  mottled,  the  white  shrunken,  and  the  red  granular, 
kidney."  Dr.  Saundby  (Path.  Soc.  Trans.,  vol.  xxxi.,  p. 
150)  has  been  from  the  first  a  consistent  and  strong 
supporter  of  this  view.  He  considers  the  small  red  and 
large  white  kidney  with  all  the  intermediate  varieties 
to  be  the  result  of  an  inflammation,  which  affects  all  the 
tissues,  but  varies  in  intensity.  The  parenchyma  of  the 
.kidney,  being  the  most  highly  organised,  necessarily  suffers 
most  in  proportion  to  the  intensity  of  the  inflammation. 
The  large  white  kidney  is  the  result  therefore  of  repeated 
severe  inflammation,  whilst  the  small  red  kidney  indicates 


CLASSIFICATION,  157' 

ail  inflammatory  process  of  prolonged  duration  but  of 
minimum  intensity,  and  the  intermediate  varieties  corres- 
pond to  all  different  degrees  of  intensity  possible  between 
these  extremes. 

The  more  careful  study  of  the  changes  occurring  in 
the  glomeruli,  have  shown  that  these  changes  are  com- 
mon to  the  several  forms  of  Bright' s  disease,  and  have 
also  given  us  an  insight  into  the  different  relations  they 
hold  in  the  evolution  of  the  several  varieties.  Klebs 
was  the  first  to  point  out  the  changes  that  occurred  in  the 
interior  of  the  Malpighian  corpuscles  in  the  early  stage  of 
scarlet  fever  nephritis,  which  consist  of  an  increase  of' 
nuclear  masses  so  great  as  to  fill  the  capsule,  and  com- 
press the  capillaries.  Klein  {Path.  Soc.  Trans.,  vol.  xxviii., 
p.  431)  confirmed  and  extended  Klebs  views,  and  further 
observations  have  shown  that  these  changes  in  the  glo- 
meruli are  not  limited  to  cases  of  scarlet  fever  nephritis, 
but  they  are  also  observed  in  cases  that  have  resulted  from 
exposure  to  wet  and  cold,  and  other  well  known  exciting 
causes  of  acute  nephritis  ;  so  that  although  in  these  cases 
the  parenchymatous  changes  are  well  marked  and  are  ap- 
parently primary  in  their  origin,  still  we  are  never  without 
evidence  of  some  degree  of  concurrent  glomerular  change.. 
And  though  these  are  not  so  evident,  as  in  those  typical 
cases  associated  with  scarlet  fever  nephritis,  in  which  the 
changes  in  the  glomeruli  are  apparently  primary,  still  we 
cannot  dissociate  the  two  processes  as  two  distinct  inflam- 
mations, but  must  consider  them  as  the  result  of  a  diffuse 
inflammation,  in  which  the  alteration  of  one  element  is  at 
one  time  more  prominent  than  another,  according  to  the  in- 
tensity or  duration  of  the  inflammatory  process.  The 
same  holds  good  with  regard  to  the  development  of  the 
granular  kidney  in  chronic  nephritis.  This  has  been 
illustrated  by   Professor   Greenfield    {Path.    Soc.    Trans.,, 


158  DISEASES    OF    THE    KIDNEY. 

vol.  xxxi.,  p.  157),  who  considers  that  the  changes  seen 
in  the  most  typical  forms  of  chronic  Bright's  disease, 
may  he  regarded  as  due  to  primary  changes  in  the  vessels 
and  glomeruli,  or  more  accurately  in  the  glomeruli  first, 
then  concurrently  in  the  arteries  and  the  excretory  tract. 
He  shows  that  these  glomerular  changes  are  of  almost  con- 
stant occurrence  in  chronic  Bright's  disease,  whilst  falso 
present  in  most  acute  cases.  The  relation,  according  to 
him,  of  the  large  white  kidney  and  the  granular  contracted 
kidney,  lies  in  the  fact,  that  whilst  the  former  is  essentially 
a  diffuse  interstitial  and  parenchymatous  inflammation,  in 
which  changes  in  the  glomeruli  are  associated  with  general 
interstitial  inflammation  ;  the  granular  contracted  kidney 
in  its  most  typical  form  is  not  necessarily  attended  by 
interstitial  inflammation,  but  may  be  dependent  on  prim- 
ary glom'erular  change  for  its  complete  evolution,  and  that 
the  subsequent  changes  are  mainly  atrophic. 

The  classification,  therefore,  that  seems  most  in  accord- 
ance with  the  views  at  present  held,  may  be  thus  briefly 
expressed. 

Acute  Nephritis. — (a)  Tubal  Nephritis.  (Syn.,  parenchymatous,  catar- 
rhal, or  desquamative  nephritis).  A  very  acute  form^  primarily  and  mainly 
affecting  the  epithelium,  and  passing  by  gradual  steps  into  a  chronic  stage. 
■(b)  Acute  Interstitial  Nephritis.  (Syn.,  glomerular  nephritis).  A  less  acute 
form  in  which  the  glomeruli  are  mainly  and  primarily  attacked,  often 
■characterised  by  considerable  interstitial  exudation.  The  renal  tubules 
and  epithelium  become  secondarily  affected,  dependent  on  the  degree  and 
■duration  of  the  inflammatory  process. 

Cheonic  Nephritis.— (a)  Chronic  Tubal  Nephritis.  (Syn.,  sub-acute 
interstitial,  chronic  parenchymatous,  non-desquamative  nephritis)  A 
transitional  sub-acute  form,  may  result  from  either  of  the  preceding,  or 
originate  independently.  It  may  pass  through  three  stages.  1.  En- 
largement, by  epithelial  proliferation  and  intertubal  growth  (large  white 
kidney).  2.  Regression  and  fatty  degeneration  (pale  granular  kidney). 
4J.  Contraction  caused  by  atrophic  changes  in  the  preceding  form  (small 
fatty  granular  kidney),  {b)  Chronic  Interstitial  Nephritis.  (Syn.,  renal 
cirrhosis,  chronic  desquamative  nephritis).  Essentially  a  chronic  form, 
■commencing  with  changes  in  the  glomeruli  and  vessels,  atrophy  subse- 


ALBUMINURIA.  159 

quently  taking  place  in  the  parts  supplied  with  these  vessels,  together 
with  some  degree  of  interstitial  overgrowth,  and  which  is  represented 
typically  by  the  small  red  granular  kidney. 

47.  Causes  of  Albuminuria. — After  having  discussed 
the  nature  of  the  inflammatory  process  that  produces  the 
■variety  of  changes  noticed  in  different  stages  of  Bright's 
disease,  it  remains  to  say  something  relative  to  the  chnical 
and  pathological  significance  of  albuminuria,  a  symptom 
which  at  one  time  was  considered  as  being  solely  associated 
with  this  form  of  disease.  Eecent  research,  however, 
has  shown  that  albuminuria  has  a  far  wider  clinical  signifi- 
cance than  its  relationship  to  diffused  inflammation,  and 
that  it  is  associated  with  many  other  morbid  conditions, 
such  as  disturbances  of  digestion,  innervation,  the  intro- 
duction of  toxic  matters  into  the  blood,  &c.  We  have 
therefore  now,  in  any  given  case  of  albuminuria,  to  con- 
sider whether  it  arises  from  organic  lesion  or  from  de- 
rangement of  function,  whilst  again  these  two  classes  may 
be  again  differentiated  into  other  groups,  thus  : 

1.  Oeganic  Albuminuria.— (a)  Renal.  1.  DiiFused  nephritis  or 
Bright's  disease.  2.  Cyanotic  induration  of  kidneys  in  heart  disease. 
3.  Degenerative  changes  in  kidneys,  as  in  parenchymatous  degenerations, 
which  is  the  cause  of  febrile  albuminuria,  and  in  lardaceous  degenera- 
tion. 4.  New  growths,  infiltrations,  and  parasites  of  the  kidney  may  give 
rise  to  albuminuria,  by  causing  intlammation  or  irritation.  (6)  Extra- 
renal in  which  the  albumin  is  mainly  derived  from  the  pus  formed  in 
the  genito-urinary  tract,  as  in  pyelitis,  suppurative  nephritis,  cystitis, 
urethritis,  &c. 

2.  Functional  Albuminuria.  1.  In  derangements  of  the  nervous 
system.  2.  Derangements  of  digestion.  3.  Alt'ered  conditions  of  the 
blood.    4.  And  in  the  so-called  physiological  albuminuria. 

With  regard  to  the  causes  that  lead  to  the  transudation 
of  albumin  into  the  urine  in  disease,  or  perhaps  to  speak 
more  accurately,  the  condition  that  prevents  its  passage 
from  the  renal  capillaries  into  the  urine  in  health,  is  still 
the  subject  of  considerable  difference  of  opinions. 


160  DISEASES    OF    THE    KIDNEY. 

In  the  first  place  with  respect  to  the  question,  how  it  is 
that  the  renal  capillaries  do  not  constantly  transude  a 
small  quantity  of  albumin,  since  the  systemic  capillaries 
throughout  the  body  generally  transmit  a  fluid  containing 
serum  albumin  ? 

The  reply  usually  given  to  this  question  is  : — 

(a)  That  the  epithelium  covering  the  glomeruli,  or  lining 
the  urinary  tubules,  has  the  power  of  re-absorbing  the  al- 
bumin transuded  by  the  vessels  of  the  glomeruli,  or  of  the 
tubules,  whilst  it  permits  the  x^assage  of  the  water,  the  urea^ 
and  saline  constituents.  When  albumin  appears  in  the 
urine,  according  to  this  yiew,  it  is  owing  either  to  the  des- 
truction of  the  renal  epithelium,  such  as  occurs  in  organie 
diseases  ;  or  to  an  arrest  of  its  function  which  for  a  time 
is  impaired  or  lost,  and  this  it  is  urged  is  what  happens  in 
the  so-called  functional  albuminuria. 

{}})  Others  have  urged  the  view,  that  as  the  rapidity  of 
the  circulation  of  the  blood  in  the  normal  Malpighian 
vessels  is  probably  greater  than  in  any  other  capillaries, 
in  the  body,  that  this  is  the  cause  why  under  ordinary 
circumstances,  albumin  does  not  transude ;  and  it  is  urged 
that  whilst  under  normal  pressure,  water  and  salts  only 
pass  out,  an  increase  of  pressure  is  requu'ed  to  ensure  the- 
passage  of  the  blood  serum.  This  augmented  pressure- 
may  be  induced  by  changes  in  the  kidney  itself ;  or  by  a  dis- 
turbance of  the  general  arterial  j)ressure  due  to  disorders 
of  other  excretory  organs,  especially  of  the  skin  and 
bowels  ;  or  from  derangement  of  the  nervous  system,  local,, 
general,  or  reflex ;  or  from  obstruction  of  the  return  of 
venous  blood,  as  in  heart  disease.  In  addition  to  these  two 
distinct  views,  all  parties  agree  that  the  passage  of  albumin 
into  the  urine  is  facilitated  by  an  altered  condition  of  the 
blood,  especially  as  regards  its  specific  gravity,  and  also 
that  albuminuria  is  occasionally  the  result  of  the  presence, 
in  excess,  of  abnormal  forms  of  albumin. 


ALBUMINUEIA.  161 

As  to  which  of  the  two  views  is  correct,  the  following 
considerations  will  perhaps  enable  us  to  form  an  opinion  : 

(1)  The  view  that  the  layer  of  epithelium  covering  the 
glomeruli  or  lining  the  tubules,  has  the  power  of  retain- 
ing albumin  in  health,  and  preventing  its  transudation 
into  the  urine,  requires  perhaps  further  experimental 
enjuiry  before  it  can  be  accepted  as  a  complete  explanation. 

Still  as  Professor  Hamilton  {oj-).  cit.)  has  pointed  out, 
there  are  several  membranes  which  are  possessed  of 
very  remarkable  properties  of  a  similar  kind.  Thus  the 
shell  membrane  of  the  fowl's  egg  will  allow  a  solution  of 
sugar  to  pass  through  it  in  one  direction  but  not  in 
another ;  the  skin  of  the  grape  has  the  same  action ;  the 
gall  bladder  retains  bile  during  life,  and  Descemet's  mem- 
brane exerts  a  similar  retentive  action  on  the  aqueous 
humour.  Thus  by  analogy  it  is  not  unreasonable  to  claim 
a  similar  protective  influence  for  the  epithelial  covering  of 
the  glomerular  loops,  or  lining  of  the  tubules,  with  regard 
to  the  passage  of  albumin. 

Clinical  evidence  also  gives  considerable  support  to  this 
view.  Dr.  Finlayson  {ojj.  cit.)  has  satisfied  himself  that  the 
epitheHum  of  the  urinary  bladder  has  the  power  of  absorbing 
albumin,  and  therefore  argues  that  the  renal  possesses  the 
same  function.  Dr.  M'Gregor  Eobertson  [op.  cit.)  arguing 
from  the  analogy  exhibited  by  other  glands  under  the  action 
of  atropine,  holds  that  if  this  substance  influenced  the  secre- 
tion from  the  kidney  it  would  do  so  through  the  renal 
cells.  If  they  were  paralysed,  they  would  be  unable  to 
absorb  the  albumin  which  would  then  appear  in  the  urine. 
He  therefore  put  this  view  to  the  test  of  an  experiment, 
and  injected  atropine  under  the  skin  of  a  cat  whose  urine 
was  quite  free  from  albumin ;  on  the  first  and  second  day, 
the  urine  became  albuminous,  and  disappeared  on  the 
thu'd  day,  when  the  animal  seemed  quite  recovered  from 

M 


162  DISEASES    OF    THE    KIDNEY. 

the  toxic  effects  of  the  drug.  This  experiment  certainly 
affords  strong  e"sadence  as  to  the  part  played  by  the  renal 
epithelium  in  the  causation  of  albuminuria.  Again  the 
diseases  of  the  kidney  in  which  albumin  is  most  abu.ndant 
are  always  those  in  which  the  epithelium  is  mainly  and 
23rimarily  affected,  as  in  acute  nephritis,  and  chronic  tubal 
nephritis  ;  whilst  in  chronic  interstitial  nephritis,  or  the 
the  indurated  kidney  of  chronic  heart  disease,  the  albumin 
is  never  abundant  during  the  early  stages  or  progress  of 
the  disease,  though  an  increase  is  observed  towards  the 
end,  when  the  tubules  become  bared  of  their  epithelium, 
and  the  same  may  be  said  with  regard  to  lardaceous 
degeneration  of  the  kidney.  Again  in  diabetes  mellitus, 
the  albuminuria  which  so  often  sets  in  in  long  pro- 
tracted cases  towards  the  end,  is  always  associated  with 
some  desquamation  and  fatty  change  in  the  renal  epithe- 
lium. The  question  now  arises  if  the  renal  epithelium 
retains  the  albumia  transuded  in  health,  what  becomes  of 
the  albumin  ?  The  answer  generally  has  been,  that  it  is 
re-absorbed  and  removed  by  the  lymphatic  spaces  and 
channels  of  the  kidney.  Nor  is  this  supposition  so  im- 
probable as  the  opponents  of  this  view  maintain,  who  urge 
that  such  an  event  is  impossible  owing  to  the  scanty  pro- 
vision of  lymphatic  channels  in  the  organ,  since  recent 
observations  seem  to  show  that  the  kidney  is  more  abun- 
dantly supphed  with  lymphatics  than  has  been  hitherto 
supposed,  whilst  the  arrangement  of  the  tubules  gives  ample 
time  for  the  absorption  of  the  albumin,  and  its  removal 
from  the  kidney.  Thus  as  Dr.  M'Gregor  Kobertson 
[op.  cit.)  has  very  clearly  pointed  out,  the  urine  filtered 
into  the  tubule  at  first  is  comparatively  rich  in  albumin, 
but  when  the  urine  reaches  the  loop  of  Henle,  the 
amount  of  albumin  it  contains  is  greatly  diminished.  The 
contracted  diameter  of  the  loop  of  Henle,  by  delaying  the 


ALBUMINURIA.  163 

passage  of  urine,  gives  time  for  the  absorption  of  a  por- 
tion of  the  albumin. 

There  are  some,  however,  who  while  admitting  that  the 
renal  epithelium  plays  an  important  part  in  preventing 
the  transudation  of  albumin,  do  not  believe  in  its  reab- 
sorption  by  the  renal  cells.  They  consider  rather  that  the 
cells  act  mechanically  in  offering  a  physical  resistance  to 
the  transudation,  and  maintain  that  so  long  as  the  epithe- 
lium is  not  detached,  even  though  it  may  have  undergone 
considerable  change,  albuminuria  does  not  occur.  They 
illustrate  this  view  by  what  occurs  in  phosphorus  poison- 
ing. Here  there  is  extensive  destruction  of  epithelium,  but 
little  or  no  desquamation  of  the  cells,  which  have  undergone 
acute  fatty  changes,  in  these  cases  the  albuminuria  is  only 
slight,  or  may  be  absent.  In  petroleum  or  poisoning 
by  chrome  salts,  on  the  other  hand,  there  is  acute  necrosis 
and  detachment  of  renal  cells,  with  the  appearance  of  a 
considerable  amount  of  albumin  in  the  urine.  The  same, 
they  point  out,  occurs  in  tubal  nephritis,  where  the 
changes  in  the  epithelium  and  the  desquamation  are  con- 
siderable, and  which  is  characterized  by  highly  albumin- 
ous urine  ;  whilst  with  chronic  interstitial  nephritis,  before 
the  epithehum  becomes  extensively  affected,  the  albumin 
is  scanty,  or  may  be  absent,  and  does  not  appear  in  any 
considerable  amount  till  the  later  stages  of  the  disease 
when  the  tubules  are  denuded  of  epithelium.  Finally 
some  would  limit  the  albumin  retaining  function  to  the 
epithelium  of  the  glomeruli.  (Heidenhain,  op.  cit.)  Ac- 
cording to  this  view,  the  epithelium  of  the  tubules  are 
concerned  only  in  the  removal  of  urea,  uric  acid,  &c., 
whilst  the  flat  epithelium  which  covers  the  glomerular  tuft 
separates  the  water  and  salts,  and  restrains  the  albumin 
from  passing  through ;  injury  or  disturbance  of  function  of 
this  layer  being  at  once  followed  by  albuminuria.     This 

M   2 


164  DISEASES    OF    THE    KIDNEY. 

view  whicli  is  rapidly  gaining  ground,  is  supported  by  the 
experiments  of  Posner  (op.  cit.)  and  others  who  by  sud- 
denly coagulating  the  albumin  in  the  kidneys,  found  albu- 
min always  between  the  glomerular  tuft  and  its  capsule. 

(2)  The  view,  that  regards  albuminuria  as  the  result  of 
increased  pressure  in  the  renal  vessels,  naturally  com- 
mends itself  on  account  of  its  simplicity.  And  at  first 
sight  the  explanation  that  the  normal  pressure  in  the 
renal  vessels  is  only  sufficient  for  the  transudation  of 
the  water,  and  that  increase  of  pressure  is  required 
to  force  the  albumin  through  the  glomeruli  and  cause 
its  presence  in  the  urine,  seems  sufficient.  It  also  re- 
ceives support  from  experimental  evidence.  Thus  albu- 
minuria can  be  produced  by  ligature  of  the  renal  veins, 
and  also  follows  section  of  the  renal  nerves,  or  irri- 
tation of  the  spinal  cord  after  section  of  these  nerves. 
But  experiments  of  this  kind  can  hardly  be  appealed  to  as 
decisive  on  this  point,  since  the  effect  of  ligature  of  the 
renal  vessels  or  nerves  must  affect  the  general  nutrition  of 
the  kidney,  and  in  some  measure  disturb  the  function  of 
the  epithelium.  But  the  most  considerable  objection  to 
the  adoption  of  this  view  is,  that  it  is  not  borne  out  by  clini- 
cal experience.  For  instance,  if  we  take  the  albuminuria, 
the  result  of  long  standing  heart  disease,  we  do  not  meet 
with  highly  albuminous  urine,  on  the  contrary  it  is  scanty, 
and  it  is  not  till  towards  the  end  of  the  disease  when  the 
tubules  become  implicated  in  secondary  changes,  and 
pressure  is  diminished  owing  to  cardiac  failure,  that  the 
albuminuria  attains  anything  like  prominence. 

Again,  in  chronic  interstitial  nephritis,  the  polyuria 
points  to  excess  of  pressure  in  the  existing  glomeruli,  yet 
the  amount  of  albumin  is  extremely  small,  and  it  is  only 
towards  the  end  of  the  disease  when  the  vascular  pressure 
fails,  and  the  quantity  of  urine  becomes  diminished,  and 


ALBUMINURIA.  165 

the  epithelium  is  destroyed,  that  the  amount  of  albumin 
present  in  the  urine  is  at  all  significant.  Indeed,  the  fact 
that  with  the  great  destruction  of  the  epithelium,  which 
occurs  in  advanced  stages  of  this  disease,  the  albumin  is 
present  in  such  small  quantities,  has  been  advanced 
against  the  view  that  albuminuria  is  caused  by  the  loss  of 
epithelium.  But  in  answer  to  this  objection  it  may  be  urged 
that  the  vascular  supply  in  the  granular  and  contracted 
kidney  has  been  already  much  diminished  by  the  preced- 
ing process  of  contraction,  so  that  the  amount  of  albumin 
filtered  through  the  surviving  glomeruli  and  tubules,  is 
considerably  lessened,  just  as  in  cirrhosis  of  the  liver,  the 
jaundice  is  slight,  owing  to  the  previous  destruction  of  the 
vessels  supplying  the  lobules,  and  the  consequent  atrophy 
of  their  cells.  On  the  other  hand,  in  acute  and  chronic 
tubal  nephritis,  where  changes  in  the  epithelium  are  mainly 
primary,  we  have  an  excessive  amount  of  albumin,  which 
continues  till  this  form  of  kidney  disease  enters  on  the 
stage  of  atrophy  and  contraction,  when  the  amount  of  al- 
bumin dechnes  as  cardio- vascular  changes  develop  ;  and 
this  diminution  continues  so  long  as  the  increased  pressure 
is  maintained,  but  when  the  heart  begins  to  flag,  and  the 
pressure  in  the  renal  vessels  falls,  and  the  water  is 
diminished,  the  albuminuria  once  more  is  increased, 
though  never  to  the  extent  as  in  the  early  period  of  the 
disease.  Again,  in  those  cases  where  pressure  is  increased 
in  the  capillary  vessels,  in  disease  of  distinctly  nervous 
origin,  as  in  diabetes  insipidus,  one  would  expect  that  al- 
bumin would  be  transuded  parri  passu  with  the  increase 
of  hydruria,  if  the  increased  pressure  theory  was  the  cor- 
rect explanation. 

Lastly,  if  increase  of  pressure  in  the  renal  vessels  were 
the  cause  of  albuminuria,  we  should  find  albumin  more 
frequently  in  the  urine  of  healthy  subjects  after  severe. 


166  DISEASES    OF    THE    KIDNEY. 

exertion  than  we  do.  Undoubtedly  powerful  muscular  exer- 
cise does  induce  in  some  persons,  apparently  healthy,  the 
temporary  appearance  of  albumin.  But  my  experience 
accords  with  that  of  Oertels  (vide  Ziemssen,  Handbuch 
des  Allgemeinen  Therapie),  that  such  an  occurrence  is 
exceptional.  Oertels  experimented  on  thirty-three  indi- 
viduals, some  of  whom  were  in  delicate  health  and  some 
women  and  children,  these  he  made  to  ascend  considerable 
heights  and  afterwards  tested  the  urine,  in  only  one  indi- 
vidual was  it  found  albuminous  after  this  severe  exertion. 
It  is  true  that  Iieube  found  albumin  in  the  urine  in  16 
per  cent,  of  the  cases  examined  by  him,  of  soldiers  after 
long  marches,  but  when  we  reflect  that  among  adult  males, 
especially  of  the  class  on  whom  the  observation  was  made, 
the  conditions  likely  to  produce  extra  renal  albuminuria 
would  be  numerous  we  need  not  be  surprised  at  his  re- 
sults. Again,  in  making  experiments  of  this  kind  it  is 
necessary  to  particularise  the  test  employed  ;  thus,  Cha- 
teaubourg  [op.  cit.)  found  albumin  in  75  per  cent,  of  the 
urines  of  soldiers  examined  after  a  meal,  when  potassio- 
mercuric  iodide  was  employed  as  a  test,  whilst  it  was  only 
found  once  when  heat  was  used.  The  mercuric  iodide  test, 
as  it  is  well  known,  having  the  property  of  precipitating 
other  proteid  substances,  likely  to  be  found  in  urine,  be- 
sides serum  albumin. 

In  conclusion  taking  all  circumstances  into  considera- 
tion, I  believe  with  the  exception  of  those  cases,  where  the 
albumin  is  plainly  derived  from  the  liquor  puris  secreted 
from  the  mucus  surface  of  the  genito- urinary  passages,  or 
from  the  blood  poured  out  into  the  urinary  tract  from 
rupture  of  the  vessels,  or  in  those  cases  where  the  albumin 
is  not  serum  albumin,  but  some  other  proteids,  as  paraglo- 
bulin,  propeptone,  peptone,  which  being  more  diffusible  than 
serum  albumin,  pass   through  simply  in   merit  of  their 


ALBUMINUKIA.  167 

diffusibilifcy,  that  in  all  cases  of  albuminuria  the  chief  and 
primary  cause  is  to  be  attributed  to  either  the  glomerular 
or  tubular  epithelium  losing  its  function  of  retaining  the 
albuminous  portions  of  the  blood  plasma  within  the  renal 
vessels.  Undoubtedly  increase  of  tension  in  the  renal  ves- 
sels plays  a  part  in  the  causation  of  albuminuria,  though 
not  to  the  extent  claimed  for  it.  It  acts  probably  by 
bringing  a  larger  quantity  of  blood  to  the  glomeruli,  so 
that  a  larger  quantity  of  albumin  is  transuded  than  the 
epithelium  is  able  to  take  up,  and  also  perhaps  by  disturb- 
ing the  function  of  the  epithelium  as  well ;  slowing  of  the 
blood  has  also  the  same  effect.  It  is  probable,  however, 
that  mere  increase  of  pressure  is  never  sufficient  of  itself  to 
cause  albuminuria  unless  some  other  condition  is  present, 
otherwise  it  would  be  impossible  to  account  for  the  absence 
of  albuminuria  in  many  disorders  in  which  increased  pres- 
sure in  the  renal  vessels  is  undoubtedly  present.  In  fact 
as  some  observers  have  stated  albuminuria  does  not  result 
in  those  experiments  made  to  increase  the  tension  in  the 
.  kidney  by  section  of  the  nerves  unless  the  renal  vessels 
are  injured. 

Among  the  concomitant  causes  of  albuminuria,  variation 
of  the  specific  gravity  of  the  blood  must  be  regarded  as 
playing  an  important  part.  Thus,  Professor  Hamilton 
(op.  cit.)  has  pointed  out  that  any  alteration  in  the  specific 
gravity,  either  increase  or  deficiency,  will  probably  give 
rise  to  serious  obstructive  effects,  and  thus  indirectly  lead 
to  the  appearance  of  albumin  in  the  urine.  Thus  in 
chronic  tubal  nephritis,  the  specific  gravity  of  the  blood 
is  always  reduced,  sinking  as  low  as  1*020  to  1*018, 
and  in  these  cases,  caused  no  doubt  by  the  hydrsemia,  the 
result  of  the  diminished  elimination  of  water  by  the  kid- 
neys, the  transudation  of  serum  in  the  form  of  dropsy  is 
always  more  or  less  observable,  and  what  occurs  in  the 


168  DISEASES    OF    THE    KIDNEY. 

systemic  capillaries  no  doubt  occurs  in  the  renal  vessels. 
Tlie  same  probably  explains  the  occurrence  of  albuminuria 
as  the  result  of  the  ansemia  and  the  hydrsemia  attendant  on 
the  process  of  certain  chronic  diseases.  On  the  other 
hand,  increase  of  the  specific  gravity  of  the  blood  may  ex- 
plain the  albuminuria  of  an  interesting  character,  occa- 
sionally met  with  in  urines  of  high  specific  gravity,  and 
loaded  with  urea 

Again,  toxic  agents  in  the  blood  may  cause  albuminuria, 
either  by  inducing  nephritis,  or  by  their  arresting  the  func- 
tion of  the  renal  epithelium,  as  is  shown  by  the  experiment 
of  Dr.  McGregor  Eobertson  already  quoted  with  regard 
to  the  action  of  atropine.  In  considering  the  causation  of 
albuminuria  in  any  given  case,  we  must  bear  in  mind  the 
circumstances  likely  to  modify  the  amount  of  albumin 
passed  into  the  urine.  Thus,  in  chronic  interstitial 
nephritis  as  already  stated,  although  the  tension  of  the 
blood  in  the  existing  glomeruli  is  raised  to  its  highest 
pitch,  whilst  the  epithelium  in  the  late  stage  is  never  nor- 
mal, and  the  specific  gravity  of  the  blood  much  reduced, 
cu'cumstances  all  extremely  favourable  for  the  transuda- 
tion of  albumin,  *still  the  amount  passed  throughout  the 
disease  is  always  insignificant.  This  is  owing,  as  already 
explained,  to  the  fact  that  in  the  early  stage,  the  epithe- 
lium is  so  little  affected,  that  it  is  able  to  reabsorb  the 
albumin  forced  through  by  the  increased  pressure,  whilst  in 
the  later  stage  when  the  epithelium  is  destroyed,  so  little 
blood  is  brought  to  the  organ,  owing  to  the  compression  of 
the  vessels  by  the  development  of  cicatricial  tissue,  that  the 
amount  of  albumin  capable  of  transudation  is  very  much 
diminished.  A  very  similar  explanation  may  be  offered 
to  account  for  the  small  amount  of  albumin  transuded  in 
the  indurated  kidney,  or  chronic  heart  disease,  and  in  lar- 
daceous  degeneration  of  the  kidneys. 


ACUTE    NEPHRITIS.  169 


Acute  Nephritis. 


48.  Varieties. — Acute  nephritis,  as  has  been  already 
remarked  (p.  158),  occurs  either  in  a  very  acute  form  in 
which  the  epithehum  is  mainly  affected,  or  in  a  less  acute 
form  in  which  the  glomeruli  are  primarily  attacked,  the 
renal  tubules,  and  epithelium  becoming  affected  at  a  later 
stage.  No  distinction  up  to  quite  recently  was  made  be- 
tween the  two  conditions,  and  acute  inflammations  of  the 
kidney  were  spoken  of  as  catarrhal,  croupous,  parenchy- 
matous or  desquamative  nephritis.  Now,  however,  the 
more  acute  form  is  generally  spoken  of  as  tubal  nephritis, 
showing  that  the  earlier  stress  of  the  disease  has  fallen  on 
the  tubules  and  renal  epithehum,  whilst  the  less  acute 
form  is  spoken  of  as  interstitial  nephritis,  or  glome - 
rulo  nephritis,  as  pointing  to  the  increased  interstitial  exu- 
dation and  alterations  in  the  glomeruli,  which  occur  as 
primary  changes.  No  very  rigid  line,  however,  can  be 
drawn  between  the  two  conditions.  Glomerular  changes 
being  often  observed  in  quite  an  early  stage  of  tubal  and 
diffuse  nephritis  ;  whilst  it  is  rare  to  find  a  kidney  the  seat 
of  a  pure  glomerulo  nephritis,  in  which  the  renal  epithe- 
lium has  not  already  undergone  some  marked  change. 

49.  Symptoms. — In  the  hyjyercBmia  induced  by  certain 
irritants  such  as  cantharides,  oil  of  turpentine,  nitrate  of 
potash,  mustard,  cubebs,  and  copaiba,  the  symptoms  are 
those  of  intense  urinary  irritation.  There  is  an  urgent 
and  frequent  desire  to  micturate,  but  Uttle  urine  is 
passed;  what  little  there  is,  is  highly  albuminous,  and 
contains  more  or  less  blood,  from  a  distinct  hemor- 
rhage to  only  a  few  blood  corpuscles.  There  is,  however, 
no  great  shedding  of  renal  epithelium,  in  some  cases  it  has 
been  stated  to  be  quite  absent,  but  there  is  an  abundance 


170  DISEASES    OF    THE    KIDNEY. 

of  fibrin  wliicli  comes  away  as  fibrinous  moulds  or  may 
even  form  lars;e  coagula.  These  moulds  and  clots  are 
often  sufficiently  large  to  block  the  urinary  passages. 
Pain  may  be  referred  to  the  kidneys,  but  most  frequently 
it  is  felt  extending  from  the  neck  of  the  bladder  to  the 
glans  penis.  In  hypersemia  of  a  less  intense  form  the  symp- 
toms are  increased  frequency  in  passing  small  quantities  of 
urine,  accompanied  with  perhaps  a  little  strangury.  The 
secretion  is  albuminous  and  may  contain  a  few  blood  cor- 
puscles but  no  renal  epithelium  or  fibrinous  casts,  there 
may  be  a  feeling  of  weight  across  the  loin  but  no  pain  re- 
flected to  the  end  of  the  penis.  General  dropsy  is  never 
the  result  of  mere  hypersemia.  No  clinical  line,  however, 
can  be  rigidly  drawn  between  hypersemia,  and  inflamma- 
tion of  the  kidney,  nor  can  we  definitely  say  when  the  one 
passes  into  the  other. 

The  onset  of  acute  nephritis  is  generally  announced  by  a 
distinct  sense  of  chilliness  followed  by  heat  and  dryness  of 
skin.  There  is  headache,  the  pulse  is  full  and  hard, 
nausea  is  complained  of,  often  actual  vomiting,  and  there 
may  be  dull  dragging  pain  across  the  loins  and  tenderness 
on  pressure  over  the  kidney.  All  these  symptoms,  however, 
in  some  cases  may  be  absent.  The  patient  is  frequently 
called  upon  to  void  urine,  which  is  highly  albuminous,  of 
dark  colour,  from  smoky,  blood-red,  to  a  deep  chocolate- 
brown  or  black,  according  to  the  amount  present,  and 
the  reaction  of  the  urine.  The  specific  gravity  is  high, 
ranging  from  1-020  to  1*040,  the  quantity  passed  in  the 
twenty-four  hours  rarely  exceeding  500  c.c,  often  falhng 
as  low  as  250  c.c,  and  even  may  be  completely  suppressed. 
Ursemic  convulsions  often  accompany  this  condition.  The 
reaction  is  generally  acid.  The  amount  of  solid  constitu- 
ents especially  the  urea  is  diminished.  On  standing  the 
urine  deposits  an  abundant  chocolate  coloured   sediment 


ACUTE    NEPHRITIS.  171 

of  blood  corpuscles,  urates,  casts,  epithelium,  and  the 
granular  debris  of  these.  In  many  instances  it  is  diffi- 
cult to  find  the  casts,  especially  if  there  is  much  blood 
and  granular  debris  present,  but  ordinarily  they  can  be 
made  out.  They  are  found  during  the  early  stage,  as 
small  and  hyaline,  with  epithelial  cells  (epithelial  casts) 
attached,  also  blood  corpuscles  (blood  casts).  A  little  later 
on,  dark  granular  casts  make  their  appearance.  The 
epithelium  is  much  altered  in  its  shape,  and  often  diffi- 
cult to  recognise  with  certainty,  but  the  round  celled 
renal  epithelium  and  the  cylindrical  epithelium  from  the 
pelvis  of  the  kidney  should  be  looked  for.  The  nuclei  of 
these  cells  when  free  may  be  mistaken  for  blood  corpuscles, 
the  latter  bodies  are  recognised  by  their  swelling  up  when 
the  fluid  on  the  slide  is  freely  diluted  with  water. 

Within  twenty  four  hours,  if  the  inflammation  is  severe 
and  the  secretion  of  urine  much  diminished,  but  generally 
within  two  or  three  days,  drojjsy  makes  its  appearance. 
This  may  range  from  slight  puffiness,  to  an  intense 
anarsarca,  involving  the  serous  cavities,  pleura,  pericar- 
dium and  peritoneum,  or  even  causing  death  by  suffoca- 
tion, from  oedema  of  the  glottis. 

Such  are  the  general  symptoms  attendent  on  a  severe 
attack  of  acute  nephritis,  we  must  now  proceed  to  consider 
the  variability  of  the  individual  symptoms,  and  the  import 
of  such  variations.  In  severe  cases,  there  is  usually  a 
definite  onset  attended  with  marked  jjyrexia.  The  initial 
elevation  of  temperature,  however,  is  rarely  extreme, 
seldom,  if  ever,  in  the  absence  of  any  other  inflamma- 
tion, exceeding  102°  to  103°F,  during  the  progress  of 
the  disease  it  may  rise  to  104°,  but  usually  it  fluctuates 
between  102°  and  103°,  to  fall  often  very  suddenly,  rising 
again  only  in  the  event  of  a  relapse  or  secondary  com- 
plications.    In  some  of  its  features  the  temperature  chart 


172  DISEASES    OF    THE    KIDNEY. 

resembles  that  of  an  acute  pneumonia,  only  the  acme  is 
reached  more  slowly  and  the  period  of  status  more  pro- 
longed, the  sudden  declension  about  the  ninth  or  tenth 
day,  however,  is  very  hke  j)neumonia. 

The  gastric  disturbance  and  vomiting  in  the  early  stage, 
is  plainly  of  a  reflex  character,  and  is  directly  proportion- 
ate to  the  severity  of  the  inflammation ;  should  nausea 
and  vomiting  occur,  however,  during  the  progress  of  the 
disease,  it  is  to  be  referred  to  ursemic  intoxication.  The 
degree  of  pain  experienced  depends  on  the  severity  of  the 
attack.  Dickinson  {ojj.  cit.)  has  recorded  a  case  of  in- 
tense congestive  nephritis,  in  which  the  swelling  of  the 
kidney  substance  was  so  great  that  the  capsules  of  both 
were  ruptured.  Such  a  degree  of  swelling  is  however 
quite  exceptional,  as  a  rule  it  is  difficult  to  get  physical 
evidence  of  any  enlargement,  though  in  thin  persons  with 
relaxed  abdominal  walls,  the  upper  extremity  of  the  kidney 
on  either  side,  but  more  markedly  on  the  right,  may  be 
felt  swollen  and  distended. 

The  frequent  and  urgent  desire  to  pass  small  quantities  of 
water  is  most  noticeable  during  the  development  of  the  attack 
but  throughout  micturition  continues  very  frequent,  though 
the  urgency  disapjpears.  The  aviount  of  ?«'Mie  passed  in  the 
twenty-four  hours  is  always  reduced,  and  in  severe  cases 
this  reduction  is  considerable,  and  may  amount  to  com- 
plete suppression.  As  the  disease  subsides,  it  becomes 
more  profuse,  and  if  there  has  been  much  dropsy,  the 
discharge  of  water  may  become  very  profuse  indeed 
towards  convalescence.  Taking  a  series  of  cases  the 
average  amount  of  urine,  passed  during  acute  nephritis 
may  be  stated  as  from  300  to  400  c.c.  during  the  early 
stages,  and  may  be  as  much  as  2000  c.c.  to  3500  c.c. 
towards  convalescence.  The  urea  may  be  extremely  re- 
duced, indeed  almost  entirely  absent ;  cases  in  which  it 


ACUTE    NEPHRITIS.  173 

has  fallen  to  1'4  grms.,  and  even  -72  grms.,  in  the  twenty- 
hours,  have  been  recorded.  In  ordinary  cases,  however, 
the  reduction  rarely  falls  below  16'7  grms.,  instead  of 
the  normal  33"4  grms.  A  sudden  fall  after  the  es- 
tablishment of  the  disease  has  a  grave  import,  and  is 
generally  a  prelude  to  ursemic  convulsions.  In  calculating 
the  urea  it  must  be  remembered  that  owing  to  the  deficiency 
of  the  water  secreted,  the  percentage  amount  of  that 
substance  will  appear  high.  In  normal  conditions  the 
percentage  of  urea  ranges  from  two  to  three  per  cent., 
with  an  excretion  of  urine  amounting  to  1450  c.c.  in  the 
twenty-four  hours.  In  acute  nephritis,  however,  the 
percentage  of  urea  may  rise  to  four  or  five  per  cent., 
the  secretion  of  water  being,  however,  only  800  to 
400  c.c,  so  that  although  the  percentage  amount  is  higher, 
the  absolute  amount  is  decidedly  less.  Similarly  we  find 
the  specific  gravity  increased,  though  the  total  of  urinary 
solids  is  less.  Next  to  the  urea,  the  chlorides  are  the  most 
constantly  diminished,  and  this  diminution  is  tlie  most 
marked  when  there  is  any  secondary  complication  such  as 
pneumonia,  or  pleuritis,  or  peritoneal  effusion.  They  may 
fall  from  a  normal  excretion  of  say  6"2  grms.  to  less  than 
1  grm.,  and  some  instances  have  been  recorded  in  which 
they  have  temporarily  disappeared  entirely  for  a  day  or 
more.  The  j^hosj^horic  acid  is  always  reduced,  but  not  to 
the  same  extent  as  we  find  it  in  chronic  nephritis,  the 
reduction  is  chiefly  with  the  phosphoric  acid  in  combina- 
tion with  the  earthy  bases.  Uric  acid  is  frequently 
deposited  in  a  free  state,  and  the  urine  is  generally  turbid, 
with  highly  coloured  acid  urates.  Their  presence  in  such 
apparent  abundance  is  due,  however,  to  the  highly  concen- 
trated urine,  and  to  its  acidity,  and  not  to  any  real  excess. 
The  relative  excess,  however,  of  the  highly  coloured  urates, 
which  persist  nearly  throughout  the  whole  course  of  the 


174  DISEASES    OF    THE    KIDNEY, 

disease,  imparts  to  the  urine  a  deep  brown  colour,  "which 
may  be  taken  for  blood.  Blood  is  present  in  nearly  every 
case  of  acute  nephritis,  and  is  often  the  first  symptom  that 
attracts  the  patient's  attention.  The  haemorrhage  may  be 
so  slight  that  it  can  only  be  detected  by  the  presence  of 
blood  corpuscles,  or  if  it  be  exceedingly  profuse.  Nephritis 
arising  in  persons  who  have  been  exposed  to  malarial 
poison,  is  often  attended  with  this  excessive  hfematuria. 
According  to  the  quantity  of  blood  present,  the  urine 
varies  in  tint  from  a  mere  smokiness  to  chocolate  black. 
Dr.  Mahomed  {Med.  Chir.  Trans.,  1874)  has  endea- 
voured to  prove  that  there  is  a  pre -albuminuric  stage  of 
acute  Bright's  disease  in  which  only  the  crystalloids  of 
the  blood  make  their  appearance.  The  test  Dr.  Mahomed 
employs  in  proof  of  his  assertion,  is  that  of  guaiacum  and 
ozonic  ether.  This  test,  however,  as  is  well  known,  reacts 
with  many  varieties  of  albumin,  and  as  in  hyperemia  the 
fibrin  elements  of  the  blood  plasma  are  in  excess,  I 
venture  to  think  the  guaiacum  reaction  is  due  rather  to 
these  than  to  the  crystalloids  of  the  blood  ;  since  if  those 
were  present,  we  should  be  able,  which  we  are  not, 
to  demonstrate  them  by  means  of  the  spectroscope.  Dr. 
Mahomed  believed  this  presence  of  the  crystalloids  of  the 
blood  in  the  urine  of  acute  nephritis,  to  be  due  to  an  in- 
crease of  arterial  tension,  which  preceded  the  renal  inflam- 
mation. This  increase  of  tension  occurs  in  the  majority 
of  cases,  and  may  be  generally  recognized  on  the  first  day 
of  the  disease,  though  the  pulse  shortly  afterwards  becomes 
solt  and  compressible  and  often  times  exceedingly  inter- 
mitting. "With  regard,  however,  to  the  contention  that 
increased  tension  is  the  cause  of  the  guaiacum  reaction 
in  the  so-called  pre- albuminuric  state  of  acute  nephritis, 
I  do  not  think  it  can  be  admitted,  since  there  are  many 
morbid  conditions  in  which  increased  arterial  tension  is 


ACUTE    NEPHRITIS.  175 

a  marked  feature,  in  wliicli  the  urine  never  gives  the 
shghtest  reaction  with  guaiacum. 

The  haematuria  may  continue  for  a  considerable  time, 
or  may  cease  only  to  re- appear  on  an  exacerbation  of  the 
disease.  Sometimes  bloody  urine  is  only  passed  in  the 
day,  the  night  urine  being  free  from  blood.  This  gene- 
rally is  observed  in  mild  cases,  with  whom  there  is  often 
a  difficulty  in  keeping  them  strictly  to  their  bed  during 
the  day  time,  or  who  if  they  remain  in  bed  keep  constantly 
moving  about,  sitting  up  to  take  food,  etc.  The  hsema- 
turia  invariably  ceases  before  the  albuminuria,  I  have 
never  met  with  an  exception  to  this  statement. 

The  most  important  symptom  of  acute  nephritis  is  of 
course  albuminuria.  Although  the  amount  varies  consider- 
ably it  is  generally  abundant,  though  in  some  excep- 
tional cases  of  dropsy  after  scarlet  fever,  the  urine  has 
been  found  non-albuminous.  Dickinson  has  recorded 
cases  in  which  the  amount  of  dried  coagulated  albumin 
passed  into  the  urine  in  twenty- four  hours  amounted  to 
21*9  grms.  and  32* 5  grms.  These  figures  impress  us 
with  an  idea  of  the  immense  drain  that  takes  place  in  the 
system,  and  accounts  for  the  extreme  debility  and  ansemia 
that  BO  speedily  set  in.  Thus  a  patient  passing  32*5 
grms.  of  dry  coagulated  albumin  in  the  twenty- four  hours 
is  losing  during  that  period  12^  oz.  of  blood  serum,  or 
very  nearly  one-tenth  of  the  whole  mass  of  the  blood ! 
Such  cases,  however,  may  be  considered  as  exceptional 
the  general  range  in  my  experience  is  from  6  grms, 
to  13' 5  grms.  The  most  intense  albuminuria,  I  have 
met  with,  has  been  in  cases  of  puerperal  nephritis,  and 
nephritis  associated  with  ague,  the  most  moderate  in 
scarlatinal  nephritis.  The  amount  of  albumin  generally 
declines  after  the  first  day  or  so,  even  in  cases  that  eventu- 
ally terminate  fatally,  but  a  steady  daily  decrease  must  be 


176  DISEASES    OF    THE    KIDNEY. 

regarded  as  a  favourable  symptom.  For  the  purpose  of 
recording  the  amount  daily  passed,  the  method  suggested 
(p.  105)  will  give  fairly  accurate  results,  without  resorting 
to  the  tedious  process  of  drying  and  weighing  out  the 
coagulated  albumin.  Long  after  convalescence,  traces  of 
albumin  will  be  found  to  occur  in  the  urine  especially 
after  food,  or  exposure  to  cold,  so  long  as  this  condition 
lasts  the  patient  must  remain  under  observation.  No 
relationship  subsists  between  the  haematuria  and  the  albu- 
minuria. A  highly  albuminous  urine  may  contain  but 
little  blood,  whilst  profuse  hematuria  is  not  necessarily  at- 
tended with  a  high  degree  of  albuminuria.  The  character 
of  the  casts  met  with  in  acute  nephritis  have  been  already 
mentioned  (p.  141),  as  the  disease  progresses  they  become 
broader,  lose  their  epithelial  character,  and  become  dis- 
tinctly granular.  In  addition  to  the  hyaline  casts  found 
in  the  urinary  deposit,  we  find  the  renal  epithelia.  Some 
of  these  may  present  almost  a  normal  appearance  being 
only  swollen  and  more  translucent  than  ordinary,  but  re- 
taining their  nuclei.  Others  are  apparently  undergoing 
transition,  their  nuclei  being  replaced  by  inflammatory 
corpuscles.  Again  much  of  the  epithelium  is  reduced  to 
mere  granular  debris,  among  which  may  be  found  the 
white  and  red  corpuscles  of  the  blood. 

The  dropay  is  next  to  albuminuria  a  most  constant 
symptom.  Thus  Dickinson  found  oedema  in  thirty-eight 
cases  out  of  thirty-nine.  The  intensity  of  the  dropsy  is 
directly  proportionate  to  the  diminution  of  the  urinary 
secretion.  Although  the  oedema  is  general,  still  it  often 
happens,  if  the  case  be  not  severe  and  the  onset  sudden, 
that  the  dropsy  first  makes  its  appearance  in  the  most 
dependent  part ;  thus  if  the  patient  be  kept  in  bed,  across 
the  loin,  if  sitting  up  in  the  lower  limbs,  there  is  gene- 
rally, however,  some  degree  of  puffiness  of  the   eyelids 


ACUTE    NEPHRITIS.  177 

and  some  effusion  into  the  loose  connective  tissue  of  the 
penis  and  scrotum.  There  is  also  more  or  less  passive 
effusion  into  the  serous  cavities,  which  sometimes  he- 
comes  excessive.  Ascitic  effusion  is  the  most  frequent  and 
generally  the  most  extensive.  Hydrothorax  occurs  in 
about  30  per  cent,  of  recorded  cases,  whilst  effusion  into 
the  pericardium  though  generally  observed  post-mortem,  is 
rarely  clinically  demonstrable  during  life.  (Edema  of  the 
glottis  is  fortunately  of  rare  occurrence.  As  the  disease 
passes  off  and  the  urinary  secretion  becomes  free,  the 
dropsy  disappears,  sometimes  this  occurs  with  amazing 
rapidity. 

The  special  complications  that  may  arise  during  acute 
nephritis  are  : — (1)  UrcBniia,  due  in  part  to  the  reten- 
tion in  the  blood  of  the  urinary  constituents,  and  also 
to  an  alteration  in  its  percentage  composition,  from 
diminution  of  its  proteid  elements,  and  the  relative 
or  absolute  increase  of  the  extractive  matters.  Like 
dropsy  the  severity  of  its  onset  is  in  direct  proportion 
to  the  diminution  of  the  urinary  secretion.  Ursemic  con- 
vulsions are  most  commonly  associated  with  the  acute 
nephritis  arising  in  connection  with  previous  morbid  con- 
ditions, as  in  scarlet  fever  nephritis  or  in  the  puerperal 
state.  I  cannot,  however,  agree  with  Bartels  {op.  cit.), 
in  saying  that  it  does  not  occur  in  acute  nephritis  due  to 
other  causes,  though  I  admit  that  it  is  of  less  frequent 
occurrence.  (2)  Acute  affection  of  the  respiratory  organs, 
such  as  pleurisy,  pneumonia,  and  bronchitis,  are  frequent, 
especially  among  children.  Pleurisy  followed  by  purulent 
effusion,  or  pneumonia,  also  going  on  to  suppuration,  is 
perhaps  the  most  frequent  fatal  termination  of  acute  neph- 
ritis. Pulmonary  oedema  on  the  other  hand  is  not  so  com- 
mon an  event  as  it  is  in  chronic  nephritis.  (3)  Erysipelas, 
or  even  gangrene,  may  attack  oedematous  parts,  especially 


178  DISEASES    OF    THE    KIDNEY. 

if  they  have  been  punctured,  though  this  complication 
does  not  so  frequently  arise  as  in  chronic  renal  affections. 
(4)  H (Bmorrhages  rarely  occur,  unless  there  has  been  some 
previously  existing  morbid  condition  of  the  blood.  Thus 
epistaxis  sometimes,  though  rarely,  occm-s  in  the  nephritis 
of  scarlet  fever,  diphtheria,  malarial  poisoning,  or  after 
typhoid  fever,  or  small  pox,  and  in  the  nephritis  of 
pregnancy.  I  have  never  seen  retinal  hemorrhage  in  a 
case  of  acute  nephritis,  of  recent  origin,  except  in  puer- 
peral nephritis,  but  then  there  was  reason,  also,  to  suspect 
chronic  renal  mischief  the  result  of  preceding  pregnancies. 
50.  Stiology. — Prominently,  before  all  other  exciting 
conditions,  exposure  to  (1)  Cold  and  Wet  must  be  reckoned 
as  the  most  fertile  cause  of  acute  nephritis.  Dr.  Wilks  and 
Dr.  Dickinson  attribute  half  or  fifty  per  cent,  of  their  re- 
corded cases  of  acute  nephritis  to  this  cause.  At  the  Seamen's 
Hospital,  all  my  cases  of  acute  inflammatory  dropsy  could 
be  referred  to  exposure  to  weather,  especially  to  damp  cold. 
At  the  London  Hospital,  among  the  male  adult  patients 
that  have  passed  through  my  out-patient  room  into  the 
wards,  or  in  less  severe  cases,  have  been  permitted  to 
attend  as  out-patients,  I  find  quite  two-thirds  attribute  the 
disease  to  exposure  to  cold,  especially  exposure  after  hav- 
ing been  heated.  Thus  the  stevedores,  the  coal  loaders, 
and  shipwrights,  who  work  arduously  for  some  hours, 
persphing  profusely  meantime,  and  afterwards  ?tand  about 
docks  and  yards  waiting  for  fresh  jobs,  whilst  still  heated, 
and  often  exposed  to  the  keen  wind  blowing  from  the  river, 
are  frequent  victims  of  acute  nephritis.  Sugar  bakers, 
iron  founders,  etc.,  who  are  exposed  to  the  great  heat  of 
the  furnaces,  and  go  out  into  the  cold  yards  without 
putting  on  additional  clothing,  also  furnish  a  large  contin- 
gent. With  regard  to  women,  the  influence  of  cold  in  the 
production  of  acute   nephi'itis   is   less   marked,   but   the 


ACUTE    NEPHRITIS.  179 

flower  girls,  and  tlie  saleswomen  of  the  open  stalls,  supply 
us  with  more  than  occasional  examples  of  the  disease.  I 
have  never  yet  succeeded  in  obtaining  a  history  of  expo- 
sure to  cold  and  wet  in  a  case  of  acute  nephritis  occurring 
in  childhood,  though  the  numerous  waifs  and  strays  of  the 
East  End  must  often  suffer  from  this  exposure,  and 
children  are  as  liable  as  adults  to  attacks  of  acute  nephritis ; 
but  with  them  it  is  nearly  invariably  found  as  a  sequel  to 
scarlet  fever,  measles,  etc.  Perhaps  the  extreme  suscepti- 
bility of  their  respiratory  organs  to  the  influence  of  cold 
and  their  liability  to  acute  attacks  of  pneumonia  and 
bronchitis  divert  the  morbid  influence  of  cold  in  this 
direction.  Dr.  Dickinson  has  also  observed  this  immu- 
nity to  acute  nephritis  arising  from  cold  among  children, 
for  in  fifty-four  fatal  cases  recorded  by  him,  the  disease 
was  traced  to  wet  or  cold  in  but  four.  It  does  not 
appear  however  that  dry  cold,  however  severe,  is  sufficient 
to  excite  nephritis.  The  experience  of  Arctic  expeditions 
proves  this,  the  men  may  be  half  starved,  may  suffer  from 
Bcurvy,  may  pass  suddenly  from  hot  cabins  to  the  intense 
cold  of  the  outer  air,  in  fact  are  placed  in  conditions  one 
would  think  particularly  favourable  to  provoke  nephritis, 
and  yet  renal  affections  are  almost  unknown.  The  same 
may  be  said  of  the  North  American  hunters.  Dr. 
Dickinson  attributes  this  immunity  of  the  frigid  zone  from 
renal  disorders,  to  the  fact  that  the  cold  increases  the 
action  of  oxygen,  which  gives  rise  to  increased  combustion 
of  the  solids  and  fluids  of  the  body,  cold  he  thinks  exalts 
the  respiratory  function,  and  diminishes  the  formation  of 
urea,  the  kidneys  therefore  are  not  liable  to  suffer  by  the 
irritation  of  excrementitious  matter,  since  the  stress  of 
excretion  falls  on  the  lungs.  This  explanation,  however, 
is  not  quite  satisfactory,  for  if  there  is  increased  combus- 
tion taking  place  in  the  body,  the  nitrogenous  constituents 

n2 


180  DISEASES    OF    THE    KIDNEY. 

will  be  reduced  as  well  as  the  fatty,  so  that  there  will  be 
no  diminution  in  the  formation  of  urea,  true  there  may  be 
a  disproportion  between  the  excretion  of  carbonic  acid  and 
the  urea,  because  ia  Arctic  regions  more  fatty  food  is.  con- 
sumed relatively  to  the  nitrogenous,  but  there  is  no  diminu- 
tion in  conversion  of  the  latter.  Besides  this,  the  increased 
oxidation  of  the  tissues  must  lead  to  increased  formation 
of  urea,  and  by  no  other  channel  can  it  escape  from  the 
body  except  by  the  kidneys.  The  reason  I  think  why 
acute  nephritis  is  common  in  temperate,  but  rare  in  frigid 
regions,  lays  in  the  fact  that  one  is  damp  cold,  the  other 
dry  cold.  I  hold  that  damp  is  a  factor  of  greater  import- 
ance than  cold  in  the  causation  of  nephritis.  Damp  chills 
the  surface  of  the  body  more  completely  than  mere  cold, 
against  which  we  can  protect  ourselves  by  warmer  clothing. 
The  two  conditions,  however,  acting  together  are  more 
surely  productive  of  catarrhal  affections,  than  any  other 
combination. 

(2)  Next  to  cold  and  damp,  morhid  conditions  of  the  blood, 
as  induced  by  certain  acute  diseases,  play  an  important 
part  in  the  etiology  of  acute  nephritis.  Among  these, 
scarlet  fever  holds  undoubtedly  the  chief  place,  certainly 
two-thirds  of  all  the  cases  of  acute  nephritis,  occurring 
under  sixteen  years  of  age,  are  due  to  this  cause.  Preg- 
nancy is  not  unfrequently  attended  with  a  greater  or  less 
degree  of  nephritis  (see  Nephritis,  Etiological  Varieties  of) . 
Acute  nephritis  also  often  supervenes  during  the  progress 
of  such  diseases  as  diphtheria,  measles,  small-pox,  vari- 
cella, acute  rheumatism,  less  rarely  in  typhus,  enteric 
fever  and  relapsing  fever,  but  more  frequently  the  albumin- 
uria observed  is  the  result  only  of  the  high  temperature 
and  the  parenchymatous  changes  it  causes.  Other  less 
pronounced  blood  diseases  may  also  occasion  it,  thus  acute 
nephritis  sometimes,  though  rarely,  may  be  observed  on 


ACUTE    NEPHRITIS.  181 

the  outbreak  of  secondary  sypMis.  The  absorption  of  pus 
from  closed  or  ill-drained  abscesses  may  give  rise  to  it. 
Thus  Dr.  Matthews  Duncan  {Med.  Chir.  Trans.,  vol. 
Ixvii.)  speaks  of  the  copious  albuminuria  met  with  in 
cases  of  parametritis.  Albuminuria  also  is  not  infre- 
quently observed  in  the  urine  in  cases  of  empyema  before 
tapping.  I  have  noticed  it  in  cases  of  chronic  dysentery 
with  extensive  ulceration  of  the  intestine,  and  albu- 
min will  frequently  be  found  in  the  urine  in  cases  of 
strangulated  intestine.  The  albuminuria,  however,  that  is 
attendant  on  the  acute  nephritis,  consequent  on  morbid 
conditions  of  the  blood,  must  not  be  confounded  with  the 
albuminuria  that  so  frequently  occurs  in  states  of  pyrexia 
which  is  generally  variable  and  transitory.  Thus,  in 
scarlet  fever  it  often  happens  during  the  early  progress 
of  the  disease,  and  the  full  development  of  the  rash,  that 
the  urine  contains  albumin,  this  however,  as  the  tem- 
perature declines  and  the  rash  fades,  passes  off,  and  the 
urine  remains  free,  till  convalescence  has  fairly  set  in, 
when,  as  is  not  unlikely,  albumin  reappears,  but  this 
time  with  all  the  appearance  of  acute  nephritis,  to  wit, 
general  dropsy  and  bloody  urine. 

(3)  Extensive  lesions  of  the  cutaneous  surface  often  occa- 
sion nephritis,  but  what  the  rationale  of  the  process  is,  it 
is  difficult  to  decide.  Indeed,  the  question  of  the  rela- 
tionship existing  between  the  cutaneous  activity  and  the 
renal  functions,  requires  to  be  reviewed  under  the  light  of 
recent  physiological  and  pathological  data.  Bartels  has 
pointed  out,  that  when  renal  inflammation  follows  a  skin 
affection,  like  an  extensive  burn  for  instance,  the  nephri- 
tis occurs  at  the  height  of  the  malady,  and  not  after  the 
subsidence  of  the  pathological  process  in  the  skin,  as  is 
the  case  after  scarlet  fever.  Dr.  Soufchey  has  endorsed 
this  statement,  by  reference  to  a  case  of  psoriasis  under  his 


182  DISEASES    OF    THE    KIDNEY. 

treatment  at  St.  Bartholomew's  Hospital,  in  wliich  a  severe 
recurrence  of  the  skin  malady  was  attended  with  a  sharp 
attack  of  nephritis,  which  subsided  as  the  skin  affection 
improved  under  treatment.  In  a  case  of  my  own,  at  the 
London  Hospital,  of  acute  general  dermatitis,  in  an  unusu- 
ally severe  form,  and  which  was  also  seen  by  my  friend  and 
colleague,  Mr.  Tay,  during  the  development  of  the  attack, 
the  urine  was  scanty,  dark-coloured  and  albuminous,  but 
as  soon  as  the  inflammatory  process  was  over,  and  the 
patient  was  covered  with  large  patches  of  scurf  skin,  the 
nephritis  completely  subsided.  Now  had  this  been  a  case 
of  scarlet  fever,  and  as  the  patient  had  had  three  similar 
attacks  within  two  years,  that  supposition  must  be  dis- 
missed, the  nephritis  would  have  certainly  increased 
during  the  process  of  desquamation.  We  must,  therefore, 
regard  the  nephritis  of  scarlet  fever,  and  of  all  acute 
specific  diseases,  as  occasioned  by  some  special  morbid 
condition,  which  excites  renal  inflammation  during  the 
process  of  elimination.  Whilst  the  nephritis,  provoked  by 
direct  influence  on  the  cutaneous  surface,  either  from 
exposure  to  cold  and  damp,  or  following  extensive  lesions 
of  the  skin  as  after  burns,  cutaneous  eruptions,  etc.,  is 
caused  probably  by  the  non- elimination  and  consequent 
retention  in  the  blood  of  deleterious  excretory  products. 
With  regard  to  the  nature  of  the  excrementitious  matter 
thus  possibly  retained,  Fischer  proved  years  ago  that 
sodium  butyrate  injected  into  the  veins  of  animals  gives 
rise  to  nephritis.  Now  butyric  acid  is  not  only  a  consti- 
tuent of  human  sweat,  but  also  a  product  of  the  acid 
fermentation  of  pus. 

(4)  The  action  of  specific  irritants  and  powerful  diuretics 
may  induce  nephritis.  Of  these  cantharides  gives  us 
the  most  frequent  example,  in  the  intense  renal  hyperaemia 
that,  frequently  follows  the   application   of  a  blister,  or 


ACUTE    NEPHRITIS.  183 

when  it  has  been  administered  internally  for  criminal 
purposes.  Mustard  has  a  similar  but  less  powerful 
effect,  and  so  has  oil  of  turpentine.  Some  persons  are 
more  susceptible  than  others  to  the  action  of  these  sub- 
stances, and  a  very  small  blister,  or  a  very  ordinary  dose 
of  oil  of  turpentine  will  give  rise  to  very  severe  strangury. 
Nitrate  of  potash  has  also  been  known  when  given  in 
large  doses  to  occasion  nephritis.  Salicylic  acid  and  car- 
bolic acid  are  also  powerful  renal  irritants.  Cases  of  acute 
nephritis,  arising  during  acute  rheumatism,  and  scarlet 
fever,  treated  with  the  salicylates,  have  not  been  in- 
frequently recorded.  Carbonic  oxide  gas  also  induces 
nephritis,  probably,  as  Bartels  has  suggested,  by  inducing 
general  paralysis  of  the  blood  vessels,  and  preventing 
the  oxidation  of  the  blood.  Other  toxic  agents  have 
a  special  influence  on  the  kidney,  but  though  acute 
nephritis  may  be  occasioned  by  them  as  an  initial  step, 
they  generally  assume  some  other  structural  form.  Thus 
lead  plays  an  important  part  in  the  causation  of 
chronic  interstitial  nephritis.  Phosphorus,  arsenic,  anti- 
mony, the  mineral  acids,  bile  acids,  and  some  organic 
acids,  as  oxalic,  tartaric  acid,  etc.,  in  poisonous  doses  pro- 
duce acute  fatty  degeneration.  Alcoholic  intoxication  often 
gives  rise  to  albuminuria,  but  I  do  not  think  that  single 
large  doses  of  alcohol  are  so  provocative  of  acute  nephritis 
as  has  been  imagined.  The  albuminuria  in  these  cases 
is,  I  believe,  due  to  a  transitory  hyperaemia,  which  subsides 
rapidly,  owing  to  the  volatility  of  the  toxic  agent.  When, 
however,  alcohol  has  been  taken  constantly  in  excess,  acute 
nephritis  may  at  length  be  induced  as  is  shown  by  the 
cases  quoted  by  Dr.  Dickinson.  As  a  general  state- 
ment, however,  it  may  be  said  that  alcoholism  is  rather 
a  predisposing  than  an  exciting  cause,  and  has  a  more 
important    bearing    on    the    etiology    of    chronic    renal 


184  DISEASES    OF    THE    KIDNEY. 

disease,  than  of  the  acute  form.  The  causes  predis- 
posing to  acute  nephritis,  are  chiefly  those  which 
greatly  depress  the  bodily  powers.  Dr.  Dickinson  has 
pointed  out  that  the  influence  of  cold  is  most  mischievous 
during  exhaustion  or  sleep.  Chronic  alcoholism  has  un- 
doubtedly the  same  effect.  Defective  sanitary  conditions 
must  always  be  considered  as  an  important  predisposing 
cause,  and  in  epidemics  of  scarlet  fever  their  influence  is 
especially  to  be  marked  in  the  numbers  who  fall  victims  to 
acute  nephritis,  in  proportion  of  those  attacked  with  the 
fever. 

(5)  Family  predisposition  may  in  some  cases  be  traced, 
though  the  heredity  of  the  disease  is  not  nearly  so  plainly 
marked  as  with  primary  granular  kidney.  Thus,  at  Don- 
caster,  I  saw  a  lad  of  nineteen,  two  of  whose  brothers 
had  died  previously  about  the  same  age  of  acute  inflam- 
matory dropsy.  Again,  about  two  years  ago,  I  saw  a 
man,  aged  thirty-five,  as  an  out-patient  at  the  London 
Hospital,  with  acute  nephritis  who  told  me  his  father  died 
of  Bright's  disease  at  the  age  of  forty-seven,  and  also  a 
brother. 

(6)  Sex  and  Age. — The  disease,  as  might  naturally  be 
expected,  is  more  common  among  the  male  sex,  owing  to 
their  greater  exposure  to  the  influence  of  cold,  exhausting 
employments,  and  more  general  indulgence  in  alcohol. 
But  as  Dr.  Dickinson  has  pointed  out,  from  statistics 
of  Dr.  Tripe,  that  in  children  were  the  habits  of  the  sexes 
are  the  same,  scarlatinal  dropsy  occurs  in  males,  in 
the  proportion  of  sixty  males  to  thirty-nine  females,  hence 
it  may  be  inferred  that  the  "  masculine  gender  is  a  pre- 
disposing cause  "  though  the  inequality  between  the  sexes 
becomes  more  marked  in  adult  life.  Acute  nephritis 
rarely  occurs  after  fifty,  putting  aside  the  cases  that  arise 
after  scarlet  fever,  and  which  are  most  frequent  between 


ACUTE    NEPHEITTS.  185 

the  fifth  and  the  fifteenth  year,  we  find  the  period  at  which 
the  kidneys  are  most  susceptible  to  attacks  of  acute  inflam- 
mation to  be  from  the  20th  to  the  35th  year,  the  first  half 
of  the  epoch  of  adult  life. 

51.  Differential  diagnosis. — We  have  to  distinguish: 

(1)  between  those  cases  in  which  we  have  a  discharge  of 
bloody  and  albuminous  urine,  and  acute  nephritis  ;    and 

(2)  between  the  acute,  sub-acute,  and  chronic  varieties  of 
nephritis.  With  reference  to  the  first  class  of  cases,  it 
has  been  already  stated  that  the  albuminuria  which 
so  frequently  occurs  during  fever  of  any  kind  is  not 
always  to  be  considered  as  evidence  of  nephritis.  In 
small-pox,  measles,  typhus  fever,  acute  rheumatism,  and 
diphtheria,  albuminuria  is  a  frequent  symptom,  com- 
mencing early  in  the  disease  and  passing  away  as  it 
declines,  and  though  true  nephritis  does  occur  in  these 
diseases,  it  certainly,  with  the  exception  of  the  last,  is  a 
comparatively  rare  complication,  and  when  present  occurs 
towards  the  termination  of  the  illness.  Haematuria,  when 
present,  may  lead  one  to  form  a  wrong  diagnosis,  since  in 
many  hemorrhagic  forms  of  small-pox,  acute  rheumatism, 
scurvy,  purpura,  etc.,  and  in  certain  intermittent  fevers, 
bloody  and  albuminous  urine  is  a  special  feature.  In 
these  cases,  however,  dropsy  is  never  present,  nor  is  the 
urinary  secretion  and  urea  diminished  in  so  marked  a 
manner  as  in  acute  nephritis.  Temporary  albuminuria 
may  sometimes  occur  during  acute  rheumatism,  as  the 
result  of  embolism  of  the  renal  vessels,  as  distinct  from 
purely  pyrexial  albuminuria,  and  of  nephritis.  The  diag- 
nosis in  these  cases  is  often  dif&cult  and  our  conclusions 
must  be  mainly  based  on  the  general  circumstances  of 
the  case,  such  as  the  existence  of  endocarditis,  sudden 
onset  attended  with  rigors,  and  followed  by  fluctuating 
temperatures,  the  evidence  of  embohsm  in  other  organs. 


186  DISEASES    OF    THE    KIDNEY. 

etc.  The  distinction  between  the  hsematuria  of  nephritis 
and  haBmorrhages  proceeding  from  the  mucous  membrane 
of  the  lower  urinary  passages  can  be  readily  made, 
especially  if  the  points  mentioned  in  the  section  on  hse- 
maturia  (p.  118)  are  called  to  mind.  Nor  ought  there  to 
be  a  possibility  of  confounding  acute  nephritis  with  any 
stage  of  granular  or  waxy  kidney,  though  the  fact  must 
not  be  overlooked  that  intercurrent  attacks  of  acute 
inflammation  not  infrequently  occur  in  either  of  these 
conditions.  Haemoglobinuria  may  be  taken  for  acute 
nephritis,  if  only  one  sample  of  urine  come  under  ob- 
servation ;  but  the  absence  of  blood  corpuscles,  and  the 
paroxysmal  character  of  the  haemorrhage  ought  to  put 
us  right  on  this  point  at  once.  The  difficulty  of  diagnosis 
is  greatly  increased  in  cases  in  which  acute  nephritis 
supervenes  on  some  already  existing  lesion  of  the  kidney, 
as  in  renal  calculus,  cancer,  etc. 

52.  Course. — Primary  idiopathic  acute  nephritis  is  not 
in  itself  a  very  fatal  malady,  a  large  proportion  of  cases 
either  terminating  favourably,  or  else  drifting  into  the 
chronic  form  of  the  disease.  Speaking  generally,  we  may 
say  that  a  larger  proportion  of  fatal  cases  result  during 
the  early  stage  of  the  disease,  when  the  nephritis  comes  on 
after  some  extensive  lesion  of  the  skin,  this  is  especially 
the  case  after  burns  ;  or  in  connection  with  blood-poison- 
ing from  the  extensive  re- absorption  of  pus  ;  or  septic 
matter,  as  in  erysipelas,  carbuncle,  etc.  The  mortality  is 
probably  next  greatest  with  scarlet  fever  nephritis  ;  whilst 
acute  renal  inflammation  induced  by  exposure  to  cold  is 
not  often  immediately  attended  by  a  fatal  result.  On  the 
other  hand  the  cases  of  nephritis  that  arise  from  the  latter 
cause  are  more  apt,  I  think,  to  drift  into  the  chronic  form 
of  the  disease  than  those  that  arise  from  any  other  condi- 
tion.   Thus  for  instance  if  we  take  scarlet  fever  nephritis, 


ACUTE    NEPHEITIS.  187 

we  find  that  a  large  proportion  of  the  cases  so  attacked  make 
a  good  recovery,  if  they  do  not  succumb  to  the  disease  at 
its  onset.  "Whilst  with  the  cases  of  acute  inflammatory 
dropsy,  the  result  of  exposure  to  cold,  we  find  that  the 
disease  is  rarely  thrown  off  completely,  that  relapses  are 
frequent,  and  the  disease  often  drifts  into  the  chronic 
form.  This  difference  is  no  doubt  accounted  for  by 
the  fact,  that  in  scarlet  fever  nephritis,  the  disease  in  a 
large  proportion  of  cases  occurs  in  persons  otherwise 
healthy,  whereas  in  nephritis  the  result  of  cold  there  is 
nearly  always  some  existing  predisposition,  which  deter- 
mines the  inflammation  to  the  renal  organs.  Death  when 
it  occurs  directly  from  an  acute  attack  is  nearly  always 
occasioned  by  the  disturbance  of  the  renal  functions  and 
the  retention  in  the  blood  of  the  urinary  constituents  ;  in 
some  rare  cases,  however,  the  fatal  issue  is  caused  by 
sudden  oedema  of  the  glottis,  or  by  serous  effusion  into 
the  pericardium.  Suppression  of  urine  is  therefore 
always  an  ominous  symptom,  though  not  necessarily  a 
fatal  one,  since  cases  are  on  record  of  perfect  recovery, 
even  after  a  complete  suppression  for  more  than  two  days. 
Another  omen  for  evil  is  the  sudden  fall  in  the  amount  of 
urea  excreted.  This  often  precedes  complete  suppression, 
and  if  duly  noted  enables  us  to  take  precautionary 
measures.  For  this  reason  I  instruct  the  nurse  to 
measure  each  sample  of  urine  passed,  and  take  its  specific 
gravity,  in  every  case  of  acute  nephritis,  as  regularly  as  I 
would  direct  the  temperature  to  be  taken  during  the  pro- 
gress of  a  continued  fever. 

With  regard  to  the  duration  of  an  attack  of  uncompHcated 
acute  nephritis,  such  as  may  arise  after  exposure  to  cold,  or 
after  scarlet  fever,  we  usually  find,  if  things  go  well,  the 
urine  becoming  less  dark  coloured,  and  less  scanty  before 
the  end  of  the  first  week.    By  the  end  of  a  fortnight  in  the 


188  DISEASES    OF    THE    KIDNEY. 

ordinary  run  of  cases,  the  amount  of  urine  passed  nearly 
approaches  the  normal,  the  specific  gravity  has  increased, 
though  it  does  not  yet  approach  the  healthy  standard ;  and 
the  amount  of  albumin  reduced  from  "6  or  '5  per  cent,  to 
•2  or  -15  per  cent.  By  the  end  of  four  weeks  the  urine  is 
usually  normal  in  character,  except  that  it  still  contains  a 
certain  quantity  of  albumin.  If  tliere  has  been  much 
dropsy  during  the  acute  stage  of  the  disease  the  secretion 
of  urine  now  becomes  extremely  profuse  often  amounting 
to  double  the  normal  amount  (2500  to  3500  c.c.)  for  days 
together,  the  specific  gravity  being  proportionately  reduced, 
though  in  reality  the  amount  of  sohds  excreted  continues 
daily  to  increase,  as  will  be  seen  if  the  amount  of  urine 
passed,  and  its  specific  gravity  be  carefully  contrasted. 
Convalescence  is  often  extremely  tedious,  and  albumin  is 
often  found  in  the  urine  long  after  it  has  apparently  be- 
come normal.  In  one  case  that  completely  recovered, 
traces  of  albumin  were  found  in  the  urine  for  two  years 
after  the  acute  attack,  that  was  seven  years  ago,  and  the 
patient  is  now  quite  free  from  any  evidence  of  renal 
disease.  In  nephritis  associated  with  a  malarial  taint  this 
persistence  of  albumin  is  often  very  remarkable.  Owing 
to  the  tendency  to  relapse,  the  convalescence  must  be  care- 
fully watched,  it  is  a  great  mistake  to  allow  the  patient  to 
leave  the  house  too  soon,  and  especially  to  allow  him  to 
visit  some  distant  health  resort,  with  a  view  to  the  re- 
establishment  of  his  health — long  railway  journeys  are 
particularly  to  be  avoided. 

53.  Morbid  Anatomy.  —  The  structural  changes 
found  in  the  kidney  the  result  of  acute  nephritis  vary  with 
the  intensity  and  duration  of  the  inflammation.  In  the 
less  acute  form,  the  kidney  appears  more  rounded,  thicker 
and  heavier  than  the  normal  organ,  whilst  on  section  the 
cortex  seems  more  swollen  than  usual,  there  is,  however, 


ACUTE    NEPHRITIS.  189 

no  very  marked  hypersemia,  the  chief  apparent  change 
being  in  the  tubular  epithehum  which  becomes -swollen 
and  granular.  This  swelling  of  the  glandular  epithelium 
(cloudy  swelling)  is  greater  in  the  convoluted  portion  of 
the  tubule,  and  is  the  cause  of  the  enlargement  of  the 
cortex.  The  swelling  may  be  so  great  as  to  obstruct  the 
lumen  of  the  tubule,  either  from  the  simple  swelling,  or 
by  the  accumulation  of  detached  masses.  The  enlarge- 
ment of  the  cells  is  due  apparently  to  increase  of  the  reti- 
cular structure,  and  gives  to  them  a  granular  appearance, 
and  which  is  sometimes  so  great  as  to  obscure  the  nucleus. 
This  granular  substance  is  soluble  in  acetic  acid,  which 
distinguishes  it  from  molecular  fatty  deposit.  In  these 
mild  cases,  no,  or  only  slight,  vascular  changes  are  observ- 
able, and  there  is  no  appreciable  alteration  in  the  inter- 
stitial tissue.  In  the  more  severe  cases,  however,  the 
structural  lesions  are  more  profound.  The  kidney  may  be 
swollen  to  twice  its  natural  size,  its  capsule  so  tightly 
stretched  that  it  dies  widely  apart  when  cut ;  it  strips 
off  easily,  however,  leaving  a  smooth,  but  extremely 
vascular  surface,  soft  and  friable.  The  cut  surface  drips 
with  blood,  which  obscures  the  appearance  of  the  section, 
on  washing  this  away  with  water  we  find  that  the  cortex 
is  thickened,  and  of  a  reddish-brown  or  pale-buff  colour, 
whilst  the  pyramids  are  intensely  congested.  The  thicken- 
ing of,  the  cortex  and  its  colour  depend  on  the  degree  of  in- 
flammation, and  the  amount  of  epithelial  accumulation  in 
the  convoluted  portion  of  the  tubules.  Thus  in  the  more 
congestive  forms,  such  as  follow  on  exposure  to  cold,  the 
cortex  is  swollen  and  of  a  reddish-brown  or  chocolate  hue  ; 
whilst  in  those  cases  which  are  characterised  by  excessive 
epithehal  formation,  the  cortex  is  considerably  distended, 
but  the  reddish-brown  colour,  of  increased  vascularity, 
soon   passes  into  a  pale-buff  colour,  acquired   from   the 


190  DISEASES    OF    THE    KIDNEY. 

opaque  white  epithelium  that  distends  the  tubules.  The 
Malpighian  bodies  stand  out  as  red  points  in  the  cortical 
substance.  The  intense  vascularity  both  of  the  Mal- 
pighian corpuscles,  and  of  the  pyramids,  is  due  undoubtedly 
to  the  interruption  of  the  blood  currents  in  the  inter-tubu- 
lar vessels,  caused  by  the  intra-tubular  accumulation,  lead- 
ing to  congestion  at  those  parts  of  the  organ. 


Fig.  18. — A  tubule  showing  accumulation,  etc.,  (Green's  Pathology). 

On  examination  under  the  microscope  (1)  the  tubules 
especially  in  the  cortex,  are  found  distended  with  a 
brownish  granular  material,  (fig.  18)  which  consists  of 
renal  epithelium,  blood  corpuscles,  and  a  granular  debris. 
The  epithelia  to  a  great  extent,  present  a  normal  ap- 
pearance, though  more  or  less  translucent,  but  with  the 
nucleus  retained  ;  in  others  the  nucleus  is  obscured  by  the 
granulation,  which,  as  has  been  previously  stated,  is  due 
to  increase  of  reticular  structure.  In  some  instances  the 
nuclei  of  the  epithelia  are  being  replaced  by  pus  corpus- 
cles, whilst  much  of  the  epithelium  is  reduced  to  a  simple 
granular  debris.  Should  the  process  be  continued  the 
epitheha  lose  their  swollen  granular  appearance  and  con- 
tain instead  molecular  fat.  Besides  this  accumulation 
of  swollen  epithelial  elements,  an  albuminous  exudate  or 


ACUTE    NEPHRITIS. 


191 


liyaKne  material,  furnished  from  the  vessels  surrounding . 
the  tubule  is  poured  out  on  its  interior,  forming  a  cylindri- 
cal mould,  or  cast,  to  which  some  of  the  epithelial  elements 
and  blood  corpuscles  adhere,  and  pass  away  together  with 
the  urine  (see  Casts,  p.  141).  In  some  cases  the  lumen 
of  the  tubule  may  be  blocked  with  cylindrical  fibrinous 
plugs,  when  many  tubules  are  thus  found  affected,  the 
condition  must  have  played  an  important  part  in  leading 
to  the  fatal  result.  (2)  The  connective  tissue,  or  inter-tubular 
substance,  in  all  severe  cases,  or  in  mild  cases  if  the  inflam- 
mation has  been  of  any  duration,  rarely  escapes  change. 
The  inter- tubular  connective  tissue  usually  has  an  albumin- 
ous appearance,  and  contains  numerous  small  round  cells 
among  which  may  be  seen  inflammatory  corpuscles  and 
sometimes  fatty  granules.     In  some  cases  marked  by  con- 


FlG.  19. — Acute  Nephritis,  showing,  in  addition  to  the  intra-tubular 
changes,  the  cellular  infiltration  of  the  inter-tubular  connective  tissue 
X  200  (Green's  Pathology). 

siderable  haemorrhage  (hgemorrhagic  nephritis)  the  inter- 
tubular  spaces  will  be  found  filled  with  blood.  These 
changes  are  most  marked  in  the  cortex,  and  especially  in 
the  neighbourhood  of  the  Malpighian  bodies,  and  the  cap- 


192  DISEASES    OF    THE    KIDNEY. 

siile.  Should  the  case  recover,  these  round  cells  are 
probably  removed  by  the  lymphatic  vessels,  and  the 
interstitial  tissue  regains  its  normal  condition.  If, 
however,  it  should  pass  into  the  chronic  form,  the  cellular 
infiltration  will  become  more  abundant  and  tend  to  form 
a  fibrillated  structure,  such  as  we  shall  see  occur  when  we 
come  to  consider  the  changes  that  occur  in  interstitial 
nephritis.  (3)  The  blood  vessels  are  in  all  acute  cases 
greatly  swollen  and  dilated,  and  sometimes  covered 
with  inflammatory  corpuscles.  Haemorrhages  into  the 
urinary  tubules,  are  of  frequent  occurrence  giving  rise  to 
hsematuria,  and  blood  casts  in  the  urine.  They  are  also 
frequently  found  in  the  space  between  Bowman's  capsule 
and  the  capillary  coils  of  the  glomeruli,  and  may  be  ob- 
served as  fine  brownish  streaks  on  section  of  the  kidney 
substance.  The  glomeruli  are  always  greatly  distended  with 
blood.  Such  are  the  morbid  appearances  presented  in  the 
kidney,  in  those  cases  of  acute  nephritis  in  which  the  intra- 
tubular  changes  are  predominant. 

We  must  now  consider  the  changes  that  occur  in 
that  form  of  acute  nephritis  in  which  the  glomeruli 
are  mainly  and  primarily  affected,  and  which  is  spoken 
of  by  some  as  glomerulo  nepliritis,  and  by  others 
as  an  acute  form  of  interstitial  nephritis,  or  from 
the  fact  of  being  chiefly  observed  in  connection  with 
scarlet  fever,  have  been  specially  designated  as  scarlatinal 
nephritis,  though  practically  as  regards  etiology  there 
appears  to  be  no  material  difference  between  this  and  the 
intra-tubular  form  of  the  disease.  For  though  chiefly  as- 
sociated with  scarlet  fever,  it  has  often  been  observed  in 
cases  that  have  resulted  from  exposure  to  cold  and  wet, 
and  other  well  known  exciting  causes  of  acute  nephritis. 
Klebs  {o}).  cit.,  p.  644),  who  first  described  the  condi- 
tion, showed  that  the  chief  change  consists  in  the  interior 


ACUTE    KEPHEITIS.  193 

of  the  Malpighian  corpuscles  being  filled  with  a  number  of 
small  angular  nuclei,  imbedded  in  a  finely  granular  mass. 
These  nuclei  he  considers  result  from  the  proliferation  of 
the  corpuscles  of  connective  tissue,  which  binds  together 
the  capillaries  of  the  Malpighian  tufts.  In  glomerulo- 
nephritis the  increase  of  these  nuclear  masses  is  so  great  as 
to  completely  fill  the  Mali^ighian  capsules  and  compress 
the  capillaries.  At  an  early  stage,  the  tubules  are  but 
sHghtly  affected,  there  is  a  little  cloudy  swelling  of  the 
parenchyma,  and  little  or  no  proliferation  of  the  epithelium, 
or  marked  interstitial  change.  Later,  however,  the  tubular 
changes  become  more  marked,  with  cloudy  swelling  in  the 
convoluted  portion  of  the  tubules  and  proliferation  of  the 
epithelium,  whilst  the  tubes  become  crowded  with  leuco- 
cytes.  At  the  same  time  a  cellular  infiltration  of  the 
inter-tubular  connective  tissue,  interstitial  nephritis,  com- 
mences round  the  larger  vascular  trunks  spreading  into 
the  bases  of  the  pyramids  and  the  cortex.  The  kidneys 
are  only  slightly  if  at  all  enlarged,  and  the  texture  of  the 
organ  is  firm.  The  cortex  is  dark- coloured  and  intensely 
hypersemic.  The  glomeruli  are  pale  owing  to  the  empty- 
ing of  their  capillaries  by  the  compression  of  the  nuclear 
masses,  and  appear  on  close  inspection  like  white  points. 
The  contrast,  therefore,  between  the  changes  in  intra-cap- 
sular  and  those  of  intra-tubular  nephritis,  may  thus  be 
summarized : — 

Intra-tubular  nephritis.  The  kidneys  much  swollen,  tex- 
ture friable.  The  cortex  increased  in  width,  and  rendered 
opaque  (buff  coloured)  by  the  cloudy  swelling  of  the 
parenchyma.  Considerable  prohferation  of  the  epithehum 
with  some  changes  in  the  inter-tubular  connective  tissue. 
Glomeruh  extremely  vascular,  distended  with  blood,  stand- 
ing out  as  small  red  points. 

Glomerulo-nephntis.     The  kidneys  slightly  if  at  all  en- 

0 


194 


DISEASES    OF    THE    KIDNEY. 


larged,  texture  firm.  Cortex,  dark  chocolate  colour,  ex- 
tremely hypersemic  in  the  early  stage,  little  or  no  cloudy 
swelling  or  proliferation  of  epithelium,  nor  marked  changes 
in  the  inter-tubular  connective  tissue.  Glomeruli  filled 
with  a  number  of  small  angular  nuclei,  which  so  compress 
and  empty  their  capillaries  as  to  render  them  pale,  and 
on  minute  inspection  to  appear  as  small  white  dots. 

Klein  (Path.  Soc.  Trans.,  vol.  xxviii.,  p.  431),  who  has 
extended  the  observations  of  Klebs,  has  shown  that  in 
addition  to  the  increase  of  the  nuclei  covering  the  glomeruli 


Fig.  20. — a.  Part  of  glomernli 
degenerated  into  a  hyaline  mass. 
c.  Ditto,  less  degenerated,  b.  Af- 
ferent arterioles.  d.  Thickened 
capsule  (Klein). 


Fig.  21. — a.  Longitudinal  section 
of  artery,  h.  Infiltration  round  ves- 
sels of  lymph  cells,  c.  Arteriole 
showing  hyaline  degeneration,  d. 
Outlines  of  urinary  tubes  (Klein). 


of  the  Malpighian  corpuscles,  there  is  hyaline  degeneration 
of  the  elastic  intima  of  minute  arteries,  especially  of  the 
afferent  arterioles  of  the  Malpighian  corpuscles,  and  also  a 
multiplication  of  the  nuclei  of  the  muscular  coat  of  the 
minute   arteries,    and   a   corresponding  thickness  of  the 


ACUTE    NEPHBITIS.  195 

walls  of  these  vessels.  Figs.  20  and  21  sliow  these  changes. 
Klein  is  of  opinion  that  the  anuria  and  ursemic  poisoning 
that  occurs  iu  acute  nephritis,  when  not  directly  to  be  re- 
ferred to  inter- tubular  changes,  is  caused  by  these  changes 
in  the  arterioles,  in  this  view  he  differs  from  Klebs,  who 
holds  that  anuria  in  these  cases  is  due  to  compression 
of  the  vessels  of  the  glomeruli  by  the  pressure  of  the 
nuclear  germination.  As  has  been  already  stated,  in  the 
early  stages,  the  intra-tubular  and  interstitial  changes 
are  but  slight,  but  as  the  disease  advances,  according 
to  Klein  after  the  first  week,  these  both  become  evident. 
The  parenchymatous  changes  consist  in  the  crowding  of 
the  m-inary  tubes  with  lymphoid  cells,  granular,  and 
subsequent  fatty  degeneration  of  the  epitheUum,  and 
cylinders  of  different  kinds  in  the  tubes.  These  changes 
in  the  parenchyma,  however,  according  to  Klein  are 
not  distinct  till  after  the  interstitial  changes  have 
reached  a  certain  high  degree.  The  interstitial  changes 
as  described  by  Klein  are  as  follows  : — The  infiltration 
of  the  connective  tissue  of  the  kidney  with  round  cells 
(lymphoid  or  whatever  they  may  be  called)  is  observable 
after  the  end  of  the  first  week,  commencing  round  the 
large  vascular  trunks  whence  it  spreads  to  the  bases 
of  the  pyramids,  and  especially  into  the  cortex.  This 
infiltration  of  the  cortex  is  first  observed  at  the  roots  of 
the  inter-tubular  vessels,  and  spreads  rapidly  to  the  cap- 
sule of  the  kidney,  and  among  the  convoluted  tubes 
around  the  Malpighian  corpuscles.  In  the  course  of  the 
process  considerable  parts  of  the  cortex  become  con- 
verted into  whitish,  firm,  bloodless  cellular  masses,  in 
which  Malpighian  corpuscles  and  urinary  tubes  become 
more  or  less  degenerated,  and  are  with  difficulty  recognised. 
In  some  cases,  the  infiltration  of  the  cortex  assumes  the 
character  of  adenoid  or  lymphatic  tissue.     Emboli  may  be 

o2 


196  DISEASES    OF    THE    KIDNEY. 

occasionally  found  both  in  the  larger  arterial  trunks  as 
well  as  in  minute  arteries.  The  more  extensive  the  de- 
gree of  interstitial  change,  the  more  marked  will  be  the 
parenchymatous  nephritis,  and  the  changes  in  the  tubules. 
Should  the  attack  of  acute  nephritis  terminate  in  com- 
plete recovery,  the  epithelial  changes  come  to  an  end,  the 
vascularity  subsides,  and  the  inflammatory  products  are 
either  carried  off  by  the  urine  or  are  absorbed.  If  on  the 
other  hand,  the  disease  j)asses  into  a  sub- acute  or  chronic 
stage,  further  changes  take  place  in  the  organ  leading  to 
an  alteration  in  its  appearance,  such  as  we  find  in  the 
large  smooth,  the  pale  granular,  and  the  small  fatty 
kidney. 


Chkonic  Nephbitis  or  Granular  Kidney. 

54.  Chronic  nephritis. — Chronic  nephritis  eventuates 
in  the  condition  known  as  granular  kidney.  Like  acute 
nephritis  we  find  it  existing  in  two  forms,  one  in  which  the 
tubules  are  mainly  affected,  both  by  epithehal  proliferation, 
and  intertubular  growth,  and  which  is  designated  as  chronic 
tubal  nejjhi'itis ;  the  second,  which  is  essentially  a  chronic 
form,  and  commences  with  changes  round  the  glomeruli 
and  vessels,  together  with  some  degree  of  interstitial  over- 
growth, and  which  is  commonly  termed  chronic  interstitial 
nephritis. 

Chronic  tubal  nephritis  may  either  be  a  continuation  of 
the  acute  form,  or  it  may  originate  independently.  If 
the  patient  survives  sufficiently  long,  it  passes  through  at 
least  two  stages,  viz.,  that  of  enlargement  by  epithelial 
proliferation,  and  intertubular  growth,  in  which  stage  it  is 
commonly  spoken  of  as  the  large  ivhite  kidney ;  a  stage  of 
regression,   caused  by  atrophic   and  fatty   degeneration 


CHRONIC    NEPHRITIS. 


197 


changes  taking  place  in  the  large  white  kidney,  which 
changes  ultimately  produce  what  is  known  as  the  pale 
granular  kidney.      When  the  contraction  caused  by  these 


Fig.  22. — Large  white  kidney  showing  commencing  regression. 

atrophic  changes  is  carried  to  its  fullest  extent,  and  the 
fatty  degeneration  of  the  renal  tissues  is  complete,  then  we 
have  what  is  known  as  the  small  fatty  granular  kidney. 


198 


DISEASES    OF    THE    KIDNEY. 


In  chronic  interstitial  nephritis,  the  changes  taking 
place  in  the  kidney  are  so  gradual  in  their  development, 
that  we  are  unable  to  mark  their  course  as  in  chronic 
tubal  nephritis,  in  which  the  vascular  phenomena  are 
more  pronounced.  In  some  cases  if  the  cellular  infiltra- 
tion of  the  intertubular  connective  tissue  is  excessive,  the 
kidneys  may  be  slightly  enlarged  (large  red gramdar  kidney). 


Fig.  23. — Small  fatty  granular  or  atrophic  kidney. 

But  the  process  is  usually  so  chronic  that  this  condition  is 
rarely  observed  post-mortem,  so  that  usually  when  the  kid- 
neys come  under  observation  they  are  already  contracted, 
owing  to  the  atrophy  of  the  tubular  structures,  and  the 
cicatricial  contraction  of  the  intertubular  overgrowth. 
In  typical  cases,  chronic  interstitial  nephritis  leads  to 
what  is  called  the  sniall  red  granular  kidney,  but  as  the 
condition  is  often  associated  with  fatty  degeneration,  it 
is  a  matter  of  extreme  difficulty,  especially  in  cases  that 


CHRONIC    NEPHRITIS.  199 

have  run  a  prolonged  course,  to  distinguish  between  this 
form  and  the  pale  granular  kidney,  the  result  of  tubal 
nephritis  ;  especially  as  the  red  granular  kidney  becomes 
paler  as  the  disease  advances,  owing  to  progressive  fatty 
changes,  whilst  the  pale  variety  on  the  other  hand  be- 
comes darker,  owing  to  the  absorption  of  fat,  and 
as  the  vessels  on  the  surface  become  more  vascular 
and  distinct.  Though  a  contracted  and  granular  con- 
dition of  the  kidneys  results  from  both  chronic  tubal 
nephritis  and  chronic  interstitial  nephritis  it  is  often 
difficult   to   draw    a    very    rigid   line,   histologically   be- 


FiG.  24. — Small  red  granular  kidney ;   granulations   torn  by  removal  of 

capsule. 

tween  intra-  and  inter-tubular  changes,  or  clinically  to 
distinguish  between  the  granular  condition  of  the  kidney 
resulting  from  tubal  and  interstitial  nephritis  generally  ; 
still  an  attentive  study  of  the  earlier  history  of  the  case, 
shows  that  in  their  inception  these  two  forms  present 
clinical  features  quite  distinct  from  each  other.  Thus,  in 
chronic  tubal  nephritis,  in  the  early  stage  we  have  a 
diminished  excretion  of  urine  with  high  specific  gravity, 
an  abundance  of  albumin,  and  a  special  tendency  to 
dropsy;  whilst  ursemic  symptoms,  cardio- vascular  changes, 
and  arterial  degeneration  are  not  observed  till  the  disease 


200  DISEASES    OF    THE    KIDNEY. 

has  reached  its  height,  and  the  contraction  attendant  on 
the  secondary  atrophy  considerably  advanced.  In  chronic 
interstitial  nephritis,  on  the  other  hand,  among  the  earliest 
symptoms  noticed,  is  an  increased  excretion  of  nrine  of  low 
specific  gravity,  cardio- vascular  changes,  characterised  by 
hypertrophy  of  the  left  ventricle,  and  pulse  of  high  tension, 
and  ursemic  symptoms  more  or  less  pronounced ;  whilst 
the  amount  of  albumin  present  in  the  urine  is  never  great, 
and  may  even  in  the  early  stage  be  entirely  absent ;  and 
dropsy,  the  tendency  to  which  is  so  marked  in  tubal 
nephritis,  is  never  observed,  till  quite  the  close,  when  the 
tension  in  the  aortic  system  begins  to  fail,  owing  to  de- 
generative changes  occurring  in  the  hypertrophied  left 
ventricle,  and  even  then  it  is  rarely  excessive. 


(A).    CHRONIC    TUBAL  NEPHRITIS. 

55.  Ssonptoms. — The  most  prominent  are,  great  de- 
bility accompanied  by  marked  anaemia,  scanty,  highly, 
albuminous  urine  of  high  specific  gravity ;  frequent  mic- 
turition, and  early  supervention  of  general  dropsy.  These 
symptoms  are  a  counter-part  of  those  observed  in  the 
acute  form,  only  they  are  more  insidious  in  their  onset. 
In  the  majority  of  the  cases  that  have  come  under  my 
observation  for  the  first  time,  it  was  debility  and  pallor 
that  first  drew  attention  to  the  disease.  In  these  cases, 
the  patients  only  complained  of  malaise,  but  on  enquiry 
it  was  found  that  they  were  frequently  disturbed  in  the 
night  to  urinate,  and  that  the  urine  was  albuminous. 
Of  the  remaining  cases,  more  or  less  general  oedema  was 
present,  at  the  time  the  patient  first  appHed  for  relief. 
The  course  these  cases  run,  which  develop  in  this  insidi- 
ous form,  and  do  not  originate  in  an  acute  attack,  is  as 


CHBONIC    TUBAL    NEPHEITIS.  201 

follows.  The  patient  for  a  time  has  been  feeling  languid, 
and  has  become  pallid,  a  condition  often  referred  by  him 
as  due  to  indigestion,  since  there  is  often  considerable 
dyspepsia  and  sometimes  vomiting.  On  being  questioned, 
he  will  admit  that  of  late  he  has  had  to  rise  once  or  twice 
or  even  oftener  during  the  night  to  pass  urine,  seldom  he 
notices  whether  it  is  darker  in  colour  than  usual,  till  his 
attention  is  called  to  that  particular.  Although  there  is 
no  marked  dropsy,  still  even  at  this  early  period  there  is  a 
slight  subcutaneous  oedema,  which  is  shown  by  the  slight 
indentation  left  by  the  stethoscope,  when  applied  to  the 
chest,  and  also  by  the  furrows  left  in  the  skin  by  creases 
in  the  clothes.  The  urine  when  collected  for  twenty-four 
hours  is  found  to  be  scanty  (450-600  c.c),  dark,  and  some- 
times smoky  in  colour,  of  high  specific  gravity  (1025- 
1028),  and  highly  albuminous.  The  time  when  marked 
dropsy  sets  in  is  very  variable,  the  more  closely  the  case 
approaches  the  acute  type,  the  earlier  it  is  noticed.  It 
first  appears  in  the  feet  at  night ;  or  in  one  of  the  hands, 
the  one  that  has  been  laid  upon  during  sleep ;  or  in  the 
face,  the  eyelids  especially ;  or  in  the  prepuce,  in  fact  in 
the  parts  that  are  most  dependent,  or  offer  the  least 
resistance  to  the  effusion  of  fluid  from  the  capillaries.  As 
the  disease  advances,  the  oedema  becomes  more  diffused 
and  general.  The  degree  of  dropsy  manifested  is  very 
variable,  if  the  case  come  under  treatment  early,  or  is 
not  too  far  advanced  to  respond  to  ameliorative  measures, 
the  oedema  may  not  become  excessive,  indeed  may  be  quite 
relieved;  in  neglected  cases,  or  in  those  past  remedial 
measures,  the  dropsy  often  becomes  excessive,  so  that 
rupture  of  the  skin  may  occur  at  points  where  the  pressure 
is  extreme.  Gangrenous  inflammation  may  arise  in  the 
sodden  cellular  tissue  thus  exposed  ;  it  is  particularly 
liable  to  occur  in  the  scrotum,  which  with  the  penis,  is  in 


202  DISEASES    OF    THE    KIDNEY. 

chronic  renal  dropsy  usually  very  much  distended  with 
fluid.  Extensive  effusions  likewise  occur  in  the  serous 
sacs  of  the  pleura,  the  peritoneum,  and  the  pericardium. 
In  severe  cases  there  is  also  a  considerable  watery  exuda- 
tion from  the  mucous  surfaces,  the  lungs  become  cedema- 
tous,  and  profuse  watery  discharges  are  got  rid  of  by  the 
stomach  and  bowels.  When  the  dropsy  disap^Dears,  either 
under  the  influence  of  treatment,  or  a  tendency  towards 
recovery,  the  great  emaciation  the  patient  has  undergone 
becomes  visible,  in  the  shrunken  limbs,  and  pinched 
features,  whilst  the  ivory  whiteness  of  the  skin  and  pallor 
of  the  mucous  membrane,  testifies  to  the  anaemia.  The 
great  debility  can  be  accounted  for  by  the  withdrawal  from 
the  blood  of  large  quantities  of  serum  albumin,  whilst  the 
anemia  is  no  doubt  owing  to  the  watery  condition  of  the 
blood,  and  the  relative  disproportion  between  the  cor- 
puscles and  the  mass  of  the  circulating  fluid. 

The  urine  in  the  earlier  and  in  the  fully  developed  state 
of  the  disease  is  scanty,  but  as  tlie  dropsy  is  removed,  or 
if  the  patient  survives  till  atrophic  changes  take  place,  the 
discharge  increases  till  it  may  considerably  exceed  the 
normal.  The  quantity  in  the  early  stage  may  vary  from 
almost  complete  suppression  to  about  400  to  600  c.c.  daily. 
In  the  fully  developed  stage,  the  usual  range  will  be  found 
generally,  for  adults,  to  be  from  600  c.c.  to  700  c.c. ;  whilst 
with  the  removal  of  the  dropsy,  or  during  the  atrophic 
stage,  it  may  amount  to  2000  c.c.  or  3000  c.c.  The 
colour  is  always  more  or  less  dark,  especially  in  the  earher 
stages,  whilst  the  urine  is  scanty,  but  becomes  Hghter 
when  the  flow  is  more  profuse.  The  dark  colour  is  due 
chiefly  to  the  presence  of  urates  held  in  suspension  by  the 
quantity  of  albumin  present  in  the  urine,  and  in  some  few 
cases  to  the  presence  of  blood  corpuscles.  Blood  when  it 
makes  its  appearance,  must  always  be  regarded  as  a  sign 


CHRONIC    TUBAL    NEPHRITIS.  203 

that  the  disease  is  assuming  an  acute  form ;  it  may  occur 
at  any  period  of  the  disease,  and  always  indicates  an  ex- 
acerbation of  the  affection.  There  is  invariably,  more  or 
less,  deposit,  which  consists  of  casts,  white  corpuscles,  epi- 
thelial cells,  and  granular  debris,  often  crystals  of  uric 
acid,  and  red  blood  corpuscles  if  the  disease  assumes  a 
sub-acute  character.  The  specific  gravity  of  the  urine 
whilst  the  urine  is  scanty,  is  high,  ranging  from  1028  to 
1040.  It  falls  however  in  a  constant  proportion,  as  the 
quantity  of  urine  increases,  so  that  when  the  disease  has 
assumed  the  atrophic  form,  or  the  dropsy  is  passing  off,  it 
falls  considerably  below  the  normal,  to  1012  or  even  to 
1008.  If  Trapp's  formula  be  applied  in  these  cases,  it  will 
be  seen  that  in  spite  of  these  variations,  the  amount  of 
urinary  solids  daily  excreted,  is  always  below  the  average. 
Thus  a  patient  with  a  daily  excretion  of  400  c.c.  and  a 
specific  gravity  of  1040,  passes  32  grms.,  and  a  patient  with 
an  excretion  of  2000  c.c.  and  a  specific  gravity  of  1010, 
passes  40  grms.  of  solid  matter,  whilst  as  we  have  seen 
(p.  51)  the  normal  daily  excretion  of  solid  matters  by  the 
kidneys  in  the  healthy  adult,  approaches  58  or  60  grms. 
This  decrease  of  the  amount  of  urinary  solids  in  Bright's 
disease  appears  at  first  paradoxical,  when  we  consider  the 
amount  of  blood  serum  passed  into  the  urine,  equivalent  as 
it  is  in  many  cases  to  10  or  12  grms.  of  dried  albumin,  but 
it  must  be  remembered  that  the  specific  gravity  of  the 
blood  serum  in  chronic  Bright's  disease  is  much  reduced, 
so  that  it  is  hardly  as  high  as  that  of  normal  urine  1020, 
indeed  many  observations  have  shown  it  is  often  below  it, 
1018  and  even  1015.  On  the  other  hand,  there  is  a 
great  and  positive  reduction  in  the  amount  of  urea, 
which  falls  often  as  low  as  18  to  13  grms.,  as  com- 
pared with  a  normal  excretion  of  33  grms.  This  reduc- 
tion of  the  chief  urinary  constituent  more  than  counter- 


204 


DISEASES    OF    THE    KIDNEY. 


balances  the  addition  of  albumin,  even  when  that  sub- 
stance is  present  in  large  amount,  and  fully  accounts 
for  the  diminution  of  the  urinary  solids  noticed  in  this 
disease.  Although  the  quantity  of  urea  is  always  more 
or  less  reduced,  still  the  amount  excreted  varies  con- 
siderably day  by  day.  This  variation  depends  less  on  the 
daily  formation  of  this  substance  in  the  system,  as  on  its 
elimination  by  the  kidneys,  and  consequent  accumulation 
in  the  body.  Any  aggravation  of  the  disease,  therefore,  by 
diminishing  the  renal  function  leads  to  decreased  elimina- 
tion, whilst  any  improvement  favours  its  discharge.  The 
urea  formed  in  the  body  but  not  eliminated  by  the  kidney 
is  not,  however,  retained  wholly  in  the  blood,  but  in  great 
part  passes  into  the  dropsical  effusion.  Thus,  I  have 
found  the  percentage  of  urea  in  the  fluid  withdrawn  from 
a  patient  suffering  from  chronic  renal  dropsy,  to  equal 
that  of  the  urine  passed  by  the  same  individual  on  the 
same  day. 

The  quantity  of  albumin  passed,  like  the  urea,  varies 
from  day  to  day,  it  is,  however,  during  the  earlier  period, 
and  during  the  full  development  of  the  disease  always  con- 
siderable, in  ordinary  cases  it  is  hardly  ever  less  than  6 
grms.,  whilst  in  severe  cases  it  may  amount  to  16  or  even 
20  grms.  In  the  later  stage,  when  the  kidney  becomes 
atrophic,  the  amount  of  albumin  present  in  the  urine  be- 
comes considerably  lessened.  Casts  when  the  disease  is 
established  are  always  to  be  found.  When  the  disease  is 
recent,  thin  hyaline  casts  predominate  over  the  broad,  but 
as  the  disease  advances  the  casts  become  broader  and  dis- 
tinctly granular,  whilst  waxy  and  fatty  casts  increase  in 
number  (see  p.  141). 

Alterations  in  the  organs  of  circulation  are  not  character- 
istic of  this  form  of  nephritis.  When  they  do  occur  it  is  in 
the  later  stage,  when  atrophic  changes  in  the  kidney  become 


CHRONIC    TUBAL    NEPHRITIS.  205 

well  marked.     The  disease  may  run  its  course  without  any 
febrile  manifestation,  except  that  caused  by  secondary  in- 
flammations.     As  a  rule  the  pulse  is  weak,  soft  and  fre- 
quent, and  the  heart's  sounds  are  feeble,  as  however,  the 
disease  passes  into  the  atrophic  stage,  we  begin  to  find  a 
gradually  increasing  tension  of  the  pulse,  with  increased 
cardiac  impulse,  and  finally  hypertrophy  of  the  left  ven- 
tricle.     Atheromatous  changes,  though  they  may  be  ob- 
served, are  not  characteristic  of  this  form  of  nephritis.  The 
organs  of  digestion  usually  suffer  disturbance,  from  an 
early  date,  the  tongue  is  foul,  and  there  is  a  marked  dis- 
relish, especially  for  animal  food,  though  sometimes  the  ap- 
petite may  be  keen  throughout.    The  vomiting  that  occurs 
frequently  in  chronic  Bright's  disease,  may  be  referred  to 
the  following  causes.    "When  slight,  and  occurring  on  first 
rising  in  the  morning,  it  probably  depends  on  disturbance 
of  the  nervous  centres,  through  poisoning  of  the  blood  by 
retained  excrementory  matters,  urmnia,  this  form  however  is 
more  generally  noticed  in  connection  with  the  small  granu- 
lar kidney.  When  profuse,  frequent,  and  watery,  it  probably 
is  the  result  of  the  oedema  of  the  mucous  membrane  of  the 
stomach,  the  more  so  as  it  is  generally  associated  with  a 
watery  diarrhoea.     A  rarer  form  in  which  a  glairy  acid  fluid 
is  ejected,  depends  either  on  reflex  irritation,  or  upon  a  sub- 
acute inflammation  of  the  mucous  surface  of  the  stomach 
itself.     Disorders  of  respiration,  are  chiefly  those  which 
depend  either  upon  dropsical  effusion  into  the  cavity  of  the 
pleura,  or  from  the  mucous  surface  of  the  lungs  causing 
oedema  of  those  organs,  though  attacks  of  bronchitis  and 
pneumonia  are  not  uncommon.      The  uraemic  convulsions 
which  so  frequently  attend  on   acute   nephritis,  and   are 
su,ch  characteristic  symptoms  of  chronic  interstitial   ne- 
phritis, rarely  manifest  themselves  in  this  form  of  the 
disease,  when  they  do  they  are  generally  remarked  in  con- 


206  DISEASES    OF    THE    KIDNEY. 

nection  with  extreme  dropsy,  especially  when  the  lungs  are 
affected,  or  in  the  later  stage  of  the  disease  when  the  kid- 
ney has  become  atrophied.  The  absence  of  this  compli- 
cation in  chronic  tubal  nephritis  is  no  doubt  due  to  the 
rehef  afforded  by  the  great  oedema,  which  withdraws  much 
of  the  toxic  element  from  the  blood,  since  urea  is  to  be 
found  in  abundance  in  the  effused  serum  as  in  the  vomit 
and  diarrhoeal  discharge.  Ursemic  amaurosis,  or  albu- 
minuric retinitis  are  rarely  met  with  in  the  early,  and  fully 
developed  stages  of  the  disease,  though  in  the  later  stage 
when  secondary  atrophic  changes  have  advanced  they  are 
of  frequent  occurrence. 

56.  Causes. — Chronic  tubal  nephritis  in  many  cases  un- 
doubtedly supervenes  as  a  direct  consequence  of  an  acute 
attack,  whether  produced  by  exposure  to  cold,  scarlet 
fever,  pregnancy  or  the  like.  In  many  instances  too,  it 
happens  that  though  there  may  be  no  direct  sequence 
between  the  acute  and  chronic  form  of  the  disease,  still 
we  have  the  history  of  a  previous  acute  attack,  in  which 
recovery  seems  to  have  taken  place,  followed  after  a  short 
interval  by  a  return  of 'the  albuminuria,  and  nephritis  in  a 
sub-acute  or  chronic  form.  More  frequently,  however,  the 
disease  commences  insidiously  without  any  distinct  initial 
febrile  movement,  and  has  often  made  some  progress 
before  the  patient  presents  himself  to  the  physician.  In 
these  cases  the  disease  is  induced  by  certain  exciting 
causes  acting  on  a  constitution  already  predisposed  towards 
renal  disorder.  Among  the  exciting  causes  exposure  to 
cold  and  damp  must  be  considered  first.  Here  it  is  the 
prolonged  action  of  the  agency,  rather  than,  as  in  the  case 
of  acute  nephritis,  a  sudden  exposure.  Thus,  persons 
residing  on  cold  wet  soils,  or  in  ill- constructed  damp 
dwelhngs,  or  whose  occupations  constantly  expose  them 
to  the  inclemency  of  the  weather,  and  wet  clothes,  are 


CHRONIC    TUBAL    NEPHRITIS.  207 

Bpecially  prone  to  the  disease.  Sub- soil  damp  seems  to 
have  a  powerful  effect  in  this  direction,  and  is  one  reason 
no  doubt  why  many  writers,  chiefly  American  and  Con- 
tinental, have  considered  that  malaria  is  an  important 
exciting  cause  in  producing  chronic  nephritis,  even  without 
the  intervention  of  febrile  paroxysms.  This,  however,  is 
not  borne  out  by  my  experience  at  the  Seamen's  Hospital, 
where  a  considerable  number  of  patients  suffering  from 
malarial  poisoning  are  annuaUy  admitted.  In  these  cases 
I  failed  to  establish  any  connection  between  ague  and 
chronic  tubal  nephritis.  Indeed  sailors,  as  a  class,  as  has 
been  remarked  by  other  observers,  are  not,  in  spite  of  their 
frequent  exposure  to  severe  weather,  particularly  liable  to 
chronic  renal  disorders.  The  cases  of  chronic  nephritis 
associated  with  ague  that  have  come  under  my  observa- 
tion, have  nearly  all  occurred  in  landsmen  who  have 
resided  some  time  in  a  marshy  district,  and  though 
acute  nephritis  may  often  arise  after  recent  exposure, 
and  during  the  acute  manifestations  of  intermittent 
fever,  still  I  am  disposed  to  consider  the  chronic  nephri- 
tis in  persons  who  have  been  long  exposed  to  malarial  in- 
fluences, but  are  free  from  febrile  paroxysms,  to  be  due  to 
prolonged  residence  on  a  damp  soil,  rather  than  to  the 
specific  poison  of  the  miasm  generated  by  it.  Taking  into 
consideration  the  well  known  fact,  that  sailors  as  a  class 
are  not  specially  liable  to  chronic  renal  disease,  although 
frequently  exposed  to  cold  and  wet,  and  also  the  decided 
improvement  that  the  mere  change  of  residence,  from  a 
cold  clay  soil  to  dry  gravelly,  or  sandy,  without  a  change 
of  climate,  often  effects  in  these  cases,  I  am  disposed  to 
think  that  telluric  conditions  of  cold  and  damp,  are  more 
important  than  the  same  condition  of  the  atmosphere  or 
climate.  Next  in  importance  to  the  effect  of  cold  and 
damp  in  the  production  of  chronic  nephritis,  is  the  exist- 


208  DISEASES    OF    THE    KIDNEY. 

ence  of  affections  attended  either  with  long-continued 
suppuration  as  in  diseases  of  the  joints  and  bones,  or  in 
association  with  constitutional  diseases  as  scrofula,  syphilis 
or  phthisis.  In  these  cases  it  is  usual  to  find  lardaceous 
degeneration  combined  with  the  nephritis.  Mercury  as  is 
well  known,  when  its  use  has  been  prolonged,  will  some- 
times give  rise  to  albuminuria,  but  it  is  as  yet  undecided 
whether  this  is  due  to  chronic  nephritis,  or  as  is  most 
probable  to  an  altered  state  of  the  blood,  induced  by  the 
mineral.  The  albuminuria  subsides  after  the  withdrawal 
of  the  mercury,  and  is  never  attended  with  dropsy. 
Cantharides,  turpentine,  etc.,  which  so  readily  induce 
active  hypersemia,  apparently  do  not  induce  chronic  in- 
flammation, probably,  as  Dickinson  has  suggested,  because 
their  administration  and  operation  is  transient,  and  so 
seldom  gives  rise  to  more  than  temporary  disturbance. 
Similarly  it  has  been  shown  that  alcohol  cannot  be 
regarded  as  an  exciting  cause.  Among  the  predisposing 
causes  the  constitutional  tendency  towards  renal  disease 
must  be  taken  into  account ;  just  as  some  persons  are 
more  predisposed  to  pulmonary  disorders  than  others. 
Although  the  hereditary  tendency  in  this  form  of  chronic 
nephritis  is  not  so  pronounced  as  in  the  chronic  interstitial 
form,  still  it  undoubtedly  exists,  and  in  some  instances  it 
may  be  traced  some  generations  back. 

The  predisposition  is  most  marked  during  the  earlier  years 
of  life.  In  .acute  nephritis  the  disease  is  most  frequent  be- 
ween  ten  and  twenty  years  of  age ;  in  chronic  tubal  nephri- 
tis between  twenty  and  thirty-five  years  ;  whilst  chronic 
interstitial  nephritis,  on  the  other  hand,  rarely  occurs 
till  the  fortieth  year  is  passed,  and  is  most  frequent  be- 
tween the  fiftieth  and  sixtieth  years.  Habits  of  intem- 
perance undoubtedly  predispose  to  chronic  nephritis,  and 
whilst    spirituous   liquors   are    more   concerned    in    the 


CHRONIC    TUBAL    NEPHEITIS.  209 

chronic  interstitial  form,  immoderate  indulgence  in  malt 
liquors  has  an  undoubted  influence  in  the  production  of 
this  variety  of  nephritis,  and  the  large  breweries  at  the 
East  End  of  London  furnish  us  with  a  considerable  contin- 
gent of  our  renal  cases  annually.  Overwork,  long- con- 
tinued mental  strain,  excessive  sexual  indulgence,  may  also 
be  mentioned  as  occasional  predisposing  causes  ;  whilst  in 
some  cases  it  is  impossible  to  assign  any  definite  cause  at 
all. 

57.  Differential  Diag^nosis. — This  form  of  nephritis 
may  be  taken  for  (a)  chronic  interstitial  nephritis,  espe- 
cially in  the  later  stage,  when  secondary  atrophy  has 
resulted;  the  features,  however,  that  enable  us  to  dis- 
tinguish between  the  two  forms,  will  be  best  considered 
when  the  symptoms  of  that  form  of  renal  disease 
are  discussed.  (h)  The  cyanotic  induration  of  the  kid- 
neys consequent  on  long-standing  heart  disease.  The 
urine  though  scanty  and  dark-coloured  is  never  highly 
albuminous,  and  the  casts  are  fine  and  hyaline,  never 
broad  or  granular.  The  dropsy  too,  at  first  is  limited  to 
the  area  of  the  inferior  vena  cava  and  portal  vein,  so  that 
the  dropsy  is  confined  to  anasarca  of  the  lower  limbs,  and 
the  cavity  of  the  peritoneum  (ascites).  It  is  only  in  the 
later  stages  that  the  dropsy  becomes  general,  (c)  To  dis- 
tinguish lardaceous  degeneration  from  chronic  tubal  ne- 
phritis is  sometimes  a  matter  of  difficulty,  since  the  two 
conditions  are  often  associated.  When  uncomplicated  with 
nephritis,  our  diagnosis  is  guided  by  the  following  considera- 
tions. The  etiological  conditions,  as  the  existence  of  long- 
continued  suppuration,  bone  disease,  etc. ;  the  enlarge- 
ment of  the  liver  and  spleen  if  they  are  affected ;  the  small 
quantity  of  serum  albumin  passed.  According  to  Senator 
the  urine  contains  a  larger  proportion  of  globulin,  than  in 
any  other  form  of  chronic  renal  disease.     Earity  of  casts. 


210  DISEASES    OF    THE    KIDNEY. 

small  hyaline,  and  not  granular ;  the  dropsy  chiefly 
abdominal,  owing  to  the  implication  of  the  hepatic  and 
splenic  vessels,  (d)  Temporary  albuminuria,  either  from 
functional  disturbance,  or  pyrexia,  may  be  distinguished 
from  chronic  nephritis  by  the  extreme  variations  in  the 
amount  of  albumin  discharged  either  day  by  day  or  even 
hourly,  and  which  follow  either  marked  disturbance  of  the 
digestive  functions,  or  a  rise  of  temperature.  And  that 
there  is  no  marked  diminution  of  the  urinary  soHds,  indeed 
in  many  cases  the  urea  is  markedly  increased.  No  casts 
appear  in  the  urine.  The  general  health  often  is  but 
slightly  affected,  and  there  is  rarely  any  marked  loss  in 
weight,  and  dropsy  does  not  supervene.  (e)  Chronic  dis- 
ease of  the  genito-urinary  organs  may  be  distinguished 
from  chronic  tubal  nephritis  by  the  presence  of  pus,  and 
the  symptoms  indicating  disease  of  the  lower  urinary 
passages. 

58.  Prognosis. — Chronic  tubal  nephritis  may  terminate 
in  complete  recovery,  in  temporary  arrest,  or  may  prove 
fatal,  either  at  an  early  stage,  or  be  indefinitely  prolonged  to 
the  later  stage  of  atrophy.  Although  the  prognosis  in  this 
disease  is  not  so  favourable  as  in  acute  nephritis,  still  cases 
of  perfect  recovery  do  occur.  In  young  patients,  or  when 
the  disease  at  the  outset  is  more  or  less  in  an  acute  form, 
and  is  early  recognised,  we  may  have  reason  to  hope  that 
the  inflammation  may  subside  without  permanent  damage 
being  done  to  the  renal  texture.  When  the  nephritis  is 
the  result  of  some  special  morbid  condition  of  the  blood, 
the  outlook  is  decidedly  more  favourable  than  when  it 
arises  from  exposure  to  cold.  Thus,  in  the  nephritis 
occurring  in  syphilitic  subjects  we  find  the  albuminuria 
often  rapidly  disappears  under  anti- syphilitic  treatment, 
and  Bartels  (pp.  cii.)  has  stated  that  the  amputation  of 
a    limb   affected  with   a    fistulous    opening,    or  incision 


CHRONIC    TUBAIi    NEPHRITIS.  211 

into  a  peri-pleuritic  abscess,  has  arrested  a  nephritis, 
that  without  such  rehef  would  most  likely  have  proved 
fatal.  In  the  majority  of  cases,  especially  those  in 
adults  due  to  exposure  to  cold,  and  those  which  come  on 
insidiously,  and  are  consequently  overlooked  at  the  onset, 
the  damage  done  to  the  kidney  is  so  great  that  the 
secreting  structure  cannot  recover  itself,  and  though  ap- 
parent amehoration  may  take  place  for  a  time  under  treat- 
ment and  careful  dietetic  management,  still  the  progress 
towards  ultimate  atrophy  and  contraction  goes  on.  Some- 
times this  progress  is  so  slow  as  to  give  rise  to  the  hope 
that  the  disease  is  actually  arrested,  and  the  patient 
regains  his  weight  and  colour.  But  a  careful  examination 
of  the  urine  from  day  to  day  will  show  that  the  albumin 
re- appears  on  the  slightest  provocation. 

As  a  rule,  however,  there  is  no  apparent  respite,  and 
though  the  character  of  the  disease  changes,  the  albumin 
never  quite  disappears,  but  merely  lessens  as  the  disease 
passes  into  the  stage  of  contraction ;  whilst  at  the  same 
time,  the  urine  becomes  more  and  more  abundant  as  the 
hypertrophy  of  the  ventricle  becomes  more  marked.  The 
diminution,  therefore,  in  the  quantity  of  albumin,  and  an 
increase  in  the  quantity  of  water  passed,  is  not  necessarily 
a  sign  for  encouragement,  since  it  may  merely  imply  that 
the  kidney  is  passing  into  the  latter  stage  of  the  disease. 
The  only  decidedly  favourable  prognostic  in  my  mind  is 
the  urea  reaching  the  normal  rate  of  excretion.  When  this 
occurs,  we  find  the  quantity  of  urine  passed  daily,  and  the 
specific  gravity,  becoming  more  constant,  and  approxi- 
mating more  closely  to  the  normal  standard.  With  regard 
to  the  duration  of  the  disease,  when  it  occurs  in  compara- 
tively young  subjects,  and  is  the  result  of  some  morbid 
condition  of  the  blood,  such  as  scarlet  fever,  syphilis,  etc., 
complete  recovery  need  not  be  despaired  of  even  after  the 

p2 


212  DISEASES    OF    THE    KIDNEY. 

albuminuria  lias  persisted  for  more  than  a  year.  Bartels 
(op,  cit.)  relates  two  very  conclusive  cases,  one  a  lad  after 
scarlet  fever,  in  whom  the  albuminuria  continued  for 
eighteen  months,  who  made  a  complete  recovery,  and  ten 
years  after  grew  to  be  a  vigorous  man.  The  other  a 
man  of  forty  years  of  age,  who  was  confined  to  bed  for 
an  entne  year,  but  who  afterwards  recovered  completely. 
Dickinson  (op.  cit.)  relates  the  case  of  a  medical  stu- 
dent, who  twenty  years  previously  was  seized  with  ne- 
phritis, which  continued  for  several  months.  At  the 
end  of  two  years,  the  albumin  entirely  disappeared,  but 
for  three  or  four  years  afterwards  there  persisted  a  slowly 
decreasing  amount  of  irritability  of  the  urinary  organs. 
In  1867,  more  than  twenty  years  since  the  patient  was 
first  attacked,  he  was  in  perfect  health,  and  the  urine  had 
been  perfectly  normal  for  at  least  fifteen  years  of  that 
period.  A  similar  case  has  come  under  my  own  observa- 
tion, in  the  person  of  a  professional  friend,  who  some 
thirteen  years  ago  had  a  severe  attack  of  scarlet  fever 
nephritis,  which  pursued  a  chronic  course  for  fifteen 
months,  when  definite  improvement  set  in  ;  it  was  three 
years,  however,  before  the  renal  m-itabihty  quite  subsided, 
and  traces  of  albumin  ceased  to  be  discovered  in  the  urine, 
during  the  last  ten  years,  however,  his  health  has  been 
quite  re-estabhshed,  and  the  urine  remains  perfectly 
normal.  Cases  that  succumb  during  the  development  or 
height  of  the  disease  usually  prove  fatal  within  six  months, 
if  that  period  can  be  tided  over  and  the  dropsy  relieved, 
we  may  hope  either  that  the  disease  may  terminate  in 
complete  recovery,  or  that  the  stage  of  secondary  atrophy 
will  be  indefinitely  prolonged.  With  regard  to  the  dura- 
tion of  this  period,  much  depends  on  the  severity  of  the 
original  attack,  and  the  circumstances  and  surroundings 
of  the  patient.     If  the  inflammatory  stage  has  been  much 


CHRONIC    TUBAL    NEPHRITIS.  213 

prolonged,  and  there  is  consequently  considerable  infiltra- 
tion of  the  inter-tubular  connective  tissue,  or  the  Malpig- 
hian  corpuscles  filled  by  exudation,  and  the  tubules  exten- 
sively denuded,  then  the  atrophic  changes  will  manifest 
themselves  at  an  early  period  and  steadily  progress.  If, 
however,  the  exudation  be  slight,  and  limited  in  extent, 
and  the  patient's  circumstances  such  as  will  permit  him  to 
place  himself  under  the  best  hygienic  and  dietetic  condi- 
tions, we  may  hope  to  prolong  life  for  many  years,  eleven, 
fourteen,  and  even  twenty  years  have  been  recorded.  Even 
among  the  out-patients  of  the  Hospital,  a  class  most  un- 
favourably circumstanced  as  regards  the  treatment  of  this 
form  of  disease,  one  not  infrequently  meets  with  cases 
that  have  struggled  on  for  years,  and  who  can  refer  us 
back  to  the  time  when  they  were  in-patients  suffering  from 
their  first  attack.  Should  the  kidney,  however,  become 
the  seat,  as  it  so  often  does,  of  lardaceous  degeneration, 
then  the  case  becomes  almost  hopeless,  and  the  downward 
progress  is  accelerated. 

59.  Morbid  Anatomy. — The  post-mortem  appearance 
varies  with  the  stage  of  the  disease,  if  death  takes  place 
during  the  period  of  development  and  the  height  (status)  of 
the  affection,  we  have  the  large  white  kidney  (see  fig.  22,  p. 
197)  showing  a  variable  degree  of  enlargement,  and  a  sur- 
face more  or  less  smooth.  If  the  examination  is  made  dur 
ing  the  later  stage  when  secondary  atrophic  changes  have 
taken  place,  we  find  the  organ  shrunken,  or  contracted, 
and  we  have  the  fatty  granuiar  kidney  (fig.  23)  with  a 
nodular  and  granular  surface.  Between  these  two  ex- 
tremes we  meet  with  kidneys  of  varying  size  and  degrees 
of  granulation  according  to  the  stage  at  which  they  come 
under  observation.  1.  Large  white  kidney.  The  enlarge- 
ment, especially  when  death  takes  place  during  the  height 
of  the  disease,  is  often  very  considerable.     The  capsule 


214  DISEASES    OF    THE    KIDNEY. 

which  tightly  embraces  the  organ  is  thin,  and  is  readily 
stripped  off,  leaving  the  surface  below  quite  smooth,  unless 
the  disease  has  been  somewhat  protracted,  when  nodula- 
tion  (fig.  22),  may  be  observed  the  result  of  commencing 
contraction.  The  surface  is  of  yellowish- white  colour,  like 
ivory  that  has  been  long  exposed  to  the  air,  and  is  more  or 
less  mottled  in  appearance,  whilst  scattered  over  the  organ 
are  steUate  groups  formed  by  distended  vessels.  On  sec- 
tion we  find  the  enlargement  principally  due  to  distension 
of  the  cortex,  which  is  often  thickened  to  thrice  its  size. 
This  part  of  the  organ  is  of  the  same  yellow-white  colour 
as  the  surface.  The  pyramidal  portion  is  also  enlarged, 
but  not  proportionally  to  the  same  extent  as  in  the  cortex, 
it  is  of  dark  reddish  colour,  but  is  not  so  intensely 
hyperffimic  as  is  noticed  in  acute  nephritis.  The  micro- 
scopical appearances  are  somewhat  similar  to  those 
described  in  acute  nephritis  (p.  190).  Of  the  epithelial 
elements,  a  few  cells  are  still  swollen  and  granular ;  but 
the  majority  have  undergone  retrogressive  change  and  are 
distinctly  fatty.  As  the  disease  advances,  the  fatty 
degeneration  proceeds  till  the  cells  are  destroyed,  and  the 
fat  is  deposited  in  a  free  state  on  the  tube  casts.  Most  of 
the  tubules  will  be  found  dilated,  a  few  however  are 
usually  observed  of  normal  dimensions,  and  in  these  the 
renal  cells  may  have  escaped  change.  As  a  rule,  the 
epithehum  is  desquamated  and  fills  the  tubule,  especially 
the  convoluted  portion,  and  to  which  the  distension  of  the 
cortex  is  mainly  due  ;  some  tubules,  however,  when  the 
disease  is  more  advanced,  wiU  be  found  empty  and  stripped 
of  their  epithehum.  In  addition  to  the  altered  epithelium, 
the  tubes  will  be  found  choked  with  casts — hyaline,  gran- 
ular, fatty,  and  waxy,  granular  debris,  and  sometimes  pus 
corpuscles. 

The  changes  in  the  glomeruH,  though  they  may  vary 


CHRONIC    TUBAL    KEPHKITIS. 


215 


in  individual  specimens  dependent  on  the  rapidity  of  their 
evolution,  do  not,  as  Professor  Greenfield  {Path.  Soc. 
Trans.,  vol.  xxxi.,  p.  158)  has  pointed  out,  differ  widely 
from  those  observed  in  the  acute  form  of  the  disease. 
Those  changes  as  described  on  p.  194,  we  saw  consisted  iii 
the  formation  of  nuclear  masses  covering  the  glomeruH  of 
the  Malpighian  corpuscles ;  hyaline  degeneration  of  the 
elastic  intima  of  minute  arteries,  especially  affecting  the 
afferent'arterioles ;  and  a  multiplication  of  the  nuclei  of  the 
muscular  coat  of  the  minute  arteries,  and  a  correspond- 
ing thickening  of  the  walls  of  these  vessels.  Professor 
Greenfield  thinks  that  the  most  important  changes  are 
those  found  in  the  interior  of  the  capsule,  between  the 
capsule  and  glomerulus  ;  as  when  the  space  between  the 
tuft  and  capsule  is  crowded  with  inflammatory  corpuscles, 
and  the  capsule  itself  is  thickened,  such  a  condition  lead- 
ing to  destruction  of  the  function  of  the  glomerulus. 

The  inter-tubular  connective  tissue  is  thickened ;  this  may 
be  accounted  for  by  an  increase  of  the  connective-tissue 
elements,  by  a  general  albuminous  exudation  into  the  tissue, 
and  by  the  presence  of  leucocytes  (fig.  19,  p.  191).  This 
swelling  of  the  inter-tubular  substance  together  with  the 
distension  of  the  tubules  accounts  for  the  increased  size  of 
the  organ.  Should  recovery  take  place  the  fatty  products 
pass  off  in  the  urine  or  are  absorbed,  those  tubules  that 
have  been  only  shghtly  affected  recover  themselves,  whilst 
it  is  not  improbable,  that  even  in  those  most  seriously 
impaired  the  epithelium  may  be  regenerated.  The  inter- 
tubuiar  swelling  disappears,  and  the  leucocytes  are  re- 
absorbed. Should,  however,  the  nephritis  continue, 
changes  such  as  we  shall  see  are  essentially  characteristic 
of  chronic  interstitial  nephritis  develop,  and  the  existing 
connective  tissue  is  gradually  converted  into  fibrous  tissue. 
The  fatty  degeneration  of  the  epithehum  continues,  and 


216  DISEASES    OF    THE    KIDNEY. 

by  its  removal  leaves  the  tubes  empty,  so  that  the  kidney 
diminishes  in  volume,  at  the  same  time  the  inter-tubular 
connective  tissue  begins  to  undergo  diminution  in  bulk. 
As  contraction  progresses  we  find  the  capsule  becoming 
thickened  and  coarse,  and  adhering  more  or  less  firmly  to 
the  surface  of  the  organ,  so  that  in  stripping  it  off  por- 
tions of  the  renal  tissue  come  away  with  it.  The  surface 
instead  of  being  smooth  or  shghtly  dimpled  becomes 
more  and  more  granular  (pale  granular  kidney),  and  then 
markedly  nodular,  generally  preserving  the  yellowish- white 
colour  (fig.  23)  throughout,  but  sometimes  acquiring  a 
brownish-red  shade,  especially  in  those  cases  which  have  run 
a  protracted  course.  In  these  cases,  in  the  depressions  be- 
tween the  granulations — the  superficial  vessels  wiU  be  seen 
unduly  distended  and  visible.  On  section,  the  substance 
of  the  kidneys  will  be  found  firm  and  tough,  the  tubules 
are  irregularly  dilated  and  thickened,  and  distributed 
amongst  them  are  found  numerous  microscopic  and 
macroscopic  cysts.  The  glomeruh  are  found  undergoing 
various  degrees  of  change,  many  will  be  seen  shrunk  into 
mere  fibrous  knots,  others  less  atrophied  still  show  the 
remains  of  the  capillary  tuft  surrounded  by  the  thickened 
capsule,  whilst  a  few  still  remain  without  obvious  change 
(see  fig.  26,  p.  241).  The  inter- tubular  space  which  has 
become  infiltrated  with  small  cells  shows  signs  of  increas- 
ing fibrillation  and  contraction ;  this  change  is  most 
marked  in,  indeed  at  first  is  hmited  to,  the  cortical  portion, 
and  is  most  abundant  in  the  region  of  the  capsule  and 
Malpighian  corpuscles.  Atrophy  of  the  tubules,  especially 
their  convoluted  portion,  occurs  as  a  necessary  conse- 
quence of  the  compression  caused  by  the  contraction  of 
the  fibrous  tissue  and  the  obUteration  of  the  glomeruH, 
and  the  kidneys  become  much  reduced  ia  size  and  weight. 
The  small  arteries  become  thickened  and  undergo  changes 


CHEONIC    TUBAL    NEPHEITIS.  217 

similar  to  those  that  occur  in  chronic  interstitial  nephritis, 
and  coincidently  with  these  changes  hypertrophy  of  the 
left  ventricle  takes  place.  Indeed,  at  an  advanced  stage, 
it  becomes  difficult  from  a  mere  consideration  of  the  mor- 
bid changes  to  discriminate  between  the  two.  Waxy  or 
lardaceous  degeneration  frequently  invades  the  kidney  in 
this  form  of  nephritis  ;  the  consideration  of  the  changes 
effected  by  it  will  be  found  in  the  chapter  describing  the 
degenerative  processes  taking  place  in  the  kidney  ;  it  will 
be  sufficient  to  state  here  that  though  lardaceous  degen- 
eration is  frequently  associated  with  nephritis  it  is  not 
necessarily  so,  whilst  when  lardaceous  changes  are  pri- 
mary, nephritis  is  an  almost  invariable  accompaniment. 
Fatty  infiltration  takes  place  in  all  parts  of  the  organ. 
In  the  early  and  fully- developed  stage  of  the  disease  this 
infiltration  is  considerable  and  gives  the  organ  its  rounded 
bulky  contour  and  characteristic  colour.  As  the  disease 
advances  much  of  the  fatty  deposit  is  removed.  Lique- 
faction of  the  fatty  epithelium  takes  place  so  that  the  fat 
is  discharged  in  a  free  state  in  the  urine,  adhering  as  fine 
oily  drops  to  the  tube  casts ;  some  portion  of  the  fat  is 
directly  reabsorbed.  In  consequence  of  this  removal  the 
organ  diminishes  in  bulk,  whilst  the  characteristic  white 
colour  is  not  so  distinctly  marked,  acquiring  a  greyish- 
yellow  and  then  a  brownish-red,  as  the  removal  of  the  fat 
proceeds,  and  the  vessels  on  the  surface  become  more 
vascular  and  distinct.  The  fat,  however,  is  never  entirely 
removed,  and  even  in  advanced  stages  of  the  disease  the 
inter-tubular  growth  is  still  to  be  seen  infiltrated  with 
fatty  granules. 


218  DISEASES    OF    THE    KIDNEY. 

(B).    CHRONIC  INTERSTITIAL  NEPHRITIS. 

60.  Symptoms. — When  fully  developed,  the  following 
are  the  most  characteristic  symptoms.  A  copious  dis- 
charge of  urine,  clear  and  pale,  of  low  specific  gravity, 
containing  but  a  small  quantity  of  albumin,  and  but  few 
casts.  The  pulse  has  a  high  tension,  and  the  left  heart  is 
hypertrophied.  Haemorrhages  are  common  especially  into 
the  retina  and  from  the  nose.  Ursemic  convulsions  occur 
in  nearly  all  cases.  Unlike  what  happens  in  chronic  tubal 
nephritis,  oedema  when  noticed,  only  occurs  in  the  latter 
stage  of  the  disease.  The  disease  is  extremely  insidious 
in  its  evolution,  and  has  often  far  advanced  before  the 
patient  comes  under  observation.  Even  in  those  cases  in 
which  an  acute  origin  may  be  traced,  a  long  period  usually 
intervenes  before  the  chronic  form  fully  declares  itself. 
The  first  symptoms  usually  complained  of  are,  headache 
more  or  less  persistent,  dyspepsia,  and  a  frequent  desire  to 
urinate,  especially  at  night  time.  But  not  unfrequently 
a  urffimic  convulsion,  or  even  an  attack  of  apoplexy  is  the 
first  announcement  that  a  serious  organic  disease  of  the 
kidneys  exists.  The  progress  of  a  case,  however,  not  cut 
short  by  these  accidents  may  be  thus  described.  The 
patient  complains  of  headache,  chiefly  occipital,  loss  of 
appetite,  and  perhaps  some  feehng  of  nausea.  There  is 
usually  considerable  languor,  but  the  debility  is  not  so 
marked  as  in  the  tubal  form  of  chronic  nephritis.  Other 
symptoms,  but  not  constant  ones,  are  often  met  with  in 
individual  cases,  such  as  twitching  of  the  muscles,  and 
disorders  of  vision,  itching  of  skin,  violent  neuralgic  pain 
in  the  large  nerves,  especially  of  the  sciatic  and  brachial 
trunks.  The  majority  of  patients  become  hypochondriacal 
and  depressed,  and  the  sexual  power  becomes  diminished 
or  lost.     Attacks  of  palpitation  are  frequent,  and  asthma- 


CHKONIC    INTERSTITIAL    NEPHRITIS.  219 

tic  attacks  often  trouble  the  patient,  especially  at  night 
time.  It  is  generally  for  the  relief  of  these  symptoms 
that  the  patient  at  first  seeks  advice.  On  examination  we 
find  the  pulse  full  and  incompressible,  the  left  ventricle  of 
the  heart  hypertrophied,  whilst  the  urine  when  collected  for 
twenty-four  hours,  is  found  to  be  above  the  normal,  rang- 
ing from  1800  c.c.  to  2500  c.c,  the  specific  gravity  low, 
I'OIO  to  1*012,  and  containing  traces  of  albumin,  which 
however,  in  the  early  stage  may  be  overlooked,  or  be  absent 
for  days  at  a  time.  As  the  disease  advances,  these  symp- 
toms become  more  pronounced,  uremic  convulsions  assume 
a  more  distinct  form,  and  become  more  frequent.  Epis- 
taxis  is  now  often  very  troublesome,  but  haemorrhages 
may  occur  from  the  stomach  or  other  mucous  surfaces,  and 
cerebral  haemorrhage,  as  already  stated,  is  a  frequent  ter- 
mination. The  visual  disturbances  are  also  more  common, 
and  the  ophthalmoscope  rarely  fails  to  reveal  some  degree 
of  albuminuric  retinitis  (p.  35) ;  but  amaurosis  may  occur 
without  any  ophthalmoscopic  change  being  evident,  the 
blindness  been  apparently  caused  by  the  morbid  condition 
of  the  blood.  Visceral  complications  frequently  arise,  and 
the  patient  may  be  carried  off  by  pneumonia,  bronchitis, 
pericarditis,  etc.  If  the  patient  lives  sufficiently  long,  the 
hypertrophied  heart  gradually  fails  in  power,  the  pulse 
loses  its  abnormal  tension,  the  quantity  of  urine  secreted 
diminishes,  and  dropsy  supervenes.  We  have  now  to  con- 
sider the  symptoms  as  they  present  themselves  in  indi- 
vidual cases. 

The  Urine,  especially  in  this  form  of  renal  disease 
should  be  examined  from  day  to  day,  for  if  reliance  be 
placed  on  the  analysis  of  a  few  individual  samples  taken  at 
haphazard,  the  disease  may  be  overlooked,  since  it  may 
happen,  as  it  no  doubt  frequently  does,  that  many  speci- 
mens so  examined  present  very  little  variation  from  normal 


220 


DISEASES    OF   THE   KIDNEY. 


urine.  When  therefore  we  have  reason  to  suspect  either 
from  the  high  tension  of  the  pulse,  or  from  other  general 
symptoms  that  interstitial  nephritis  exists,  the  whole  of 
the  twenty-four  hours  urine  should  be  collected  and  mea- 
sured, a  note  at  the  same  time  being  made  as  to  the 
amount  and  quahty  of  the  food  and  drink.  From  the 
earliest  stage  up  to  almost  the  very  end,  the  amount  of 
urine  will  be  considerably  increased,  ranging  from  1500 
cc.  to  2500  cc,  to  even  4000  cc  ;  this  in  itself  is  suffi- 
cient to  confirm  our  fears,  especially  if  we  find  that  the 
micturition  is  more  frequent  in  the  night  than  it  is  in  the 
day.  The  specific  gravity  of  the  urine  will  be  found  to  be 
considerably  below  the  normal,  and  to  be  in  inverse 
proportion  to  the  amount  of  urine  passed,  that  is  to  say, 
the  greater  the  secretion  the  lower  the  specific  gravity. 
On  determining  the  amount  of  urinary  soUds  by  means  of 
Trapp's  formula  it  will  be  found  that  they  are  below  the 
normal,  and  if  a  separate  estimation  be  made  of  the  var- 
ious contituents,  it  will  be  found  the  decrease  will  be 
chiefly  in  the  amount  of  urea  and  phosphoric  acid  excreted. 
The  following  table  gives  the  result  of  an  observation  ex- 
tended over  four  days,  showing  the  amount  of  urine, 
urinary  soUds,  urea,  phosphoric  acid,  and  the  specific 
gravity  in  a  typical  case  of  interstitial  nephritis,  as  con- 
trasted with  what  might,  from  his  age  and  weight  of  body, 
be  considered  his  normal  excretion. 


Quantity. 

Specific 
Gravity. 

Urinary 
Solids. 

Urea. 

Phosphoric 
Acid. 

Normal. 
Approximate. 

1450  CO. 

1-020 

58  grms. 

33-2  grms. 

2-8  grms. 

Disease. 
Calculated 
1st    Observ. 
2nd        „ 
3rd        „ 
4tli        „ 

2020  cc. 
1650    „ 
2580    „ 
2960    „ 

1008 
1-010 
1006 
1005 

32-3  grms 
33-0      „ 
30-9      „ 
29-6      „ 

22-1  grms. 
21-8       „ 
20-9      „ 
19-8      „ 

1  01  grms. 
098      „ 
0-87      „ 
0  92      „ 

CHRONIC   INTERSTITIAL    NEPHRITIS.  221 

Before  the  onset  of  ursemic  symptoms  and  the  later 
stage  of  the  disease,  or  after  an  attack  of  diarrhoea,  the 
amount  of  urine  secreted  may  fall,  and  at  the  same  time 
the  specific  gravity  may  rise  slightly,  but  still  we  find  the 
diminution  in  the  excretion  of  urea  maintained.  This 
diminution  continues  steadily  as  the  disease  advances  ;  at 
first  and  during  the  time  the  tension  in  the  vessels  is  well 
marked,  the  diminution  is  never  so  great  as  in  chronic 
tubal  nephritis,  and  in  some  cases,  at  quite  an  early 
period  it  may  not  be  much  below  the  normal,  but  with  the 
arrest  of  the  cardiac  hypertrophy  the  decrease  becomes  at 
last  considerable.  The  decrease  in  the  amount  of  phos- 
phoric acid  excreted  is  remarkable  (Zuelzer,  op.  cit.).  It 
cannot  be  accounted  for  by  diminished  ingestion,  since 
the  chlorides  and  sulphates  are  not  diminished  in  the  like 
ratio,  nor  so  constantly,  nor  is  it  probable  that  destruction 
of  the  kidneys  is  sufficient  to  account  for  it.  It  is  not  un- 
likely, however,  that  the  phosphoric  acid  is  retained  in  the 
organism  for  some  purpose  of  nutrition.  This  diminution 
of  phosphoric  acid,  should  any  doubt  exist  as  to  the  nature 
of  the  polyuria,  which  in  the  absence  of  albumin  mio-ht 
arise,  will  serve  to  distinguish  this  form  of  disease  from 
diabetes  insipidus,  in  which  the  phosphoric  acid  if  not 
actually  increased,  is  certainly  not  diminished.  Uric  acid 
is  said  to  be  diminished,  we  must  remember  however,  in 
these  cases  that  the  urine  is  exceedingly  dilute,  and  the 
percentage  yielded  will  be  very  insignificant,  and  likely  to 
mislead,  unless  we  calculate  for  the  whole  amount  of  urine  ; 
and  again,  although  uric  acid  is  highly  insoluble  in  acid 
solutions,  still  with  extremely  dilute  urine  it  may  be  a  ques- 
tion whether  the  whole  of  it  crystallises  out  when  acid  is 
added.  In  these  cases  it  is  advisable  to  concentrate  the 
urine  to  half  or  one  third  its  bulk,  so  that  the  specific 
gravity  approaches  the  normal  before  adding  the  acid. 


222  DISEASES    OF   THE   KIDNEY. 

The  amount  of  albumin  found  in  the  urine  varies  con- 
siderably. In  some  cases,  especially  in  the  early  stages 
of  the  disease,  albumin  may  be  absent  for  days  to- 
gether, some  physicians  even  go  so  far  as  to  assert  that 
the  disease  may  run  its  course  without  the  occurrence  of 
albuminuria  at  all.  That  albumin  may  be  absent  for  con- 
siderable intervals  in  the  early  stage  of  the  disease,  is  a 
matter  I  think  to  which  all  will  readily  consent.  But  the 
cases  stated  to  have  run  a  course  without  the  occurrence 
of  albuminuria  are  at  present  too  few,  and  the  observations 
not  sufficiently  thorough  to  allow  us  to  accept  the  state- 
ment without  reservation.  The  case  recorded  by  Bartels 
(op.  cit.)  is  the  strongest  at  present  brought  forward, 
still  it  is  just  possible  that  a  trace  of  albumin  may  have 
been  overlooked,  or  may  have  been  present  in  some 
of  the  urine  that  was  not  examined,  whilst  absent  in  the 
samples  tested.  With  the  extremely  delicate  tests  recently 
introduced,  the  possibility  of  failing  to  detect  the  minutest 
trace  of  albumin  is  much  diminished,  whilst  in  all  cases  of 
doubt,  not  only  should  the  urine  be  tested  day  by  day,  but 
also  individual  samples.  For  this  purpose,  Dr  Oliver's 
test  papers  are  extremely  handy,  and  the  patient  should 
be  instructed  how  to  use  them.  But  after  all,  although 
the  presence  of  albumin  helps  to  confirm  the  diagnosis,  it 
is  not  necessary  to  it,  given  a  pulse  of  high  tension,  with 
hypertrophy  of  the  left  heart,  polyuria,  the  occurrence  of 
ursemic  headaches,  and  other  general  symptoms,  the  diag- 
nosis is  already  tolerably  conclusive.  Albumin,  however, 
is  present  in  small  amounts  in  the  majority  of  cases,  but 
is  never  excessive,  even  in  the  late  stage  of  the  disease, 
when  it  becomes  more  apparent,  the  increase  even  then 
being  at  most  relative,  and  due  to  the  more  concentrated 
state  of  the  uriae.  In  this  it  forms  a  marked  contrast  to 
chronic  tubal  nephritis,  in  which  a  very  considerable  amount 


CHRONIC    INTERSTITIAL    NEPHRITIS.  223 

is  passed,  often  amounting  to  more  than  two  per  cent,  of  dry 
coagulable  albumin,  whilst  in  this  form  the  quantity  rarely 
exceeds  0*1  per  cent.,  whilst  '05  may  be  considered  the  aver- 
age in  the  generality  of  cases.  The  amount  fluctuates  con- 
siderably, it  is  increased  especially  by  exercise,  it  is  also 
often  increased  previous  to  the  onset  of  ursemic  convulsions, 
and  also  after  heavy  meals,  especially  of  an  unsuitable  kind. 
The  colour  of  the  urine  is  generally  of  a  light  yellow,  or 
greenish  yellow  tint,  and  has  often  a  turbid  opalescent 
appearance,  the  amount  of  deposit,  however,  is  usually 
sHght.  A  few  casts  will  be  found,  often  after  much  search, 
widely  distributed  in  the  collected  sediment.  They  are 
hyaline  and  mostly  narrow,  dotted  with  a  few  fine  oil 
globules.  Very  rarely  an  occasional  broad  dark  granular 
cast  may  be  observed,  when  this  is  the  case,  it  indicates 
the  supervention  of  a  nephritis  of  a  more  acute  type,  and 
which  may  occur  at  any  period  during  the  progress  of  the 
disease.  Waxy  casts  are  also  infrequent,  though  they  un- 
doubtedly do  sometimes  occur,  though  not  nearly  so  fre- 
quently as  in  chronic  tubal  nephritis.  The  sediment  also 
contains  renal  epithelium,  and  occasionally  pus  cells,  in 
looking  for  the  former,  we  must  remember  that  their  form 
is  apt  to  be  modified  by  long  immersion  in  the  urine,  so 
that  they  may  be  mistaken  for  pus  cells,  or  for  the  epi- 
theha  of  some  other  part  of  the  urinary  tract.  Generally 
however,  they  can  be  distinguished  by  their  cuboid  form, 
by  their  being  larger  than  an  ordinary  pus  corpuscle,  by 
the  distinctness  of  their  nuclei,  and  association  with  the 
few  scattered  casts.  Eed  blood  corpuscles  are  never  found, 
except  when  the  disease  is  complicated  with  some  second- 
ary affection.  Crystals  of  calcium  oxalate,  with  which  a 
few  fine  crystals  of  uric  acid  are  intermingled,  are  com- 
monly observed  dispersed  through  the  sediment  or  attached 
to  the  tube  casts. 


224  DISEASES    OF    THE    KIDNEY. 

Changes  in  the  organs  of  circulation  are  observed  early ; 
indeed,  it  is  from  the  peculiar  character  of  the  pulse,  that 
we  are  often  led  to  make  an  examination  of  the  urine,  and 
to  suspect  the  existence  of  the  disease.  The  changes  con- 
sist of  hypertrophy  of  the  left  ventricle,  thickening  of  the 
arterioles  generally  throughout  the  body,  accompanied  by 
atheromatous  degeneration.  To  the  degenerated  condi- 
tion of  the  vessels,  and  the  high  degree  of  tension  that 
exists  in  them,  the  tendency  towards  haemorrhage  is 
accounted  for,  the  most  formidable  form  being  that  from 
the  cerebral  vessels,  and  giving  rise  to  apoplexy.  These 
various  changes  and  the  conditions  they  give  rise  to,  are 
described  in  the  chapter  on  general  symptomatology  (p.  15). 
Dropsy  which  is  such  a  marked  feature  of  tubal  nephritis, 
both  in  its  early  and  fully  developed  stage  is  never  ob- 
served in  interstitial  nephritis,  except  in  the  later  stage 
when  the  arterial  tension  has  fallen,  or  unless  an  inter- 
current attack  of  sub-acute  nephritis  supervenes.  Even 
then  it  rarely  assumes  a  high  grade. 

Disturbances  of  the  nervous  system  are  also  very  marked, 
and  manifest  themselves  early  in  this  form  of  disease,  and 
are  a  feature  that  distinguish  it  from  chronic  tubal 
nephritis,  in  which  form  they  occur  late,  and  are  usually 
developed  in  connection  with  some  other  complication, 
and  are  due  mainly  to  the  toxic  condition  of  the  blood, 
and  in  part  to  the  changes  that  are  taking  place  in  the 
vessels  of  the  nerve  centres.  Sometimes  these  disturbances 
come  on  very  gradually  in  the  form  of  minor  manifesta- 
tions, at  other  times  as  a  sudden  outburst  in  the  shape  of 
ursemic  convulsions.  The  minor  disturbances  are  head- 
ache, neuralgia,  twitching  of  the  muscles,  and  itching  of 
the  skin.  The  headaches  are  generally  occipital,  and  are 
extremely  persistent,  occasionally  they  are  hemi-cranial. 
Severe  neuralgic  pain  often  accompanies  the  headache, 


CHRONIC    INTERSTITIAL    NEPHRITIS.  225 

affecting  chiefly  the  deep  seated  nerve  trunks,  and  it  often 
happens  that  whilst  the  deep  seated  nerves  are  the  seat  of 
pain,  some  of  the  superficial  branches  are  affected  with 
anesthesia.  Twitching  of  the  muscles,  generally  confined 
to  certain  groups,  is  also  a  very  annoying  symptom,  and 
usually  precedes  an  attack  of  urasmic  convulsions,  though 
I  have  noticed  the  symptom  in  quite  an  early  stage  of  the 
disease.  The  muscles  most  generally  affected  are  the 
muscles  of  the  calf  of  the  leg,  the  quadriceps  femoris,  and 
the  serratus  magnus.  Sometimes  the  patient  will  he  woke 
suddenly  in  the  night,  with  a  general  twitching  of  all  the 
superficial  muscles  of  the  body.  Violent  itching  of  the 
skin  is  another  distressing  symptom,  and  which  sets  in 
towards  the  end  of  the  disease ;  though  undoubtedly 
mainly  due  to  nervous  disorder,  it  may  be  aggravated  by 
the  state  of  the  skin,  and  the  deposit  on  it  of  minute  crys- 
tals of  urea.  The  attacks  of  ureemic  convulsions  may 
come  on  without  warning,  but  as  a  rule  they  are  pre- 
ceded by  an  aggravation  of  these  minor  nervous  disorders, 
and  by  a  marked  change  in  the  character  of  the  urine. 

Uraemic  amaurosis  without  ophthalmoscopic  changes, 
and  alhuviinuric  retinitis  are  rarely  absent  in  a  more  or 
less  pronounced  degree  in  the  fully  developed  stage  of  in- 
terstitial nephritis,  in  this  respect  they  serve  to  distinguish 
it  from  chronic  tubal  nephritis,  in  which  disorders  of  vision 
and  ophthalmoscopic  changes  do  not  occur  till  the  stage 
of  secondary  atrophy  is  developed.  An  account  of  the 
changes  that  are  observed  in  the  retina  in  this  disease,  is 
given  at  page  34. 

Disorders  of  digestion  are  manifest  throughout.  The 
appetite  fails  at  quite  an  early  stage,  especially  as  regards 
animal  food.  Vomiting  is  a  very  general  symptom,  it 
occurs  in  two  forms  ;  (a)  that  dependent  upon  an  ursemic 
condition,    and    which   usually    occurs   upon   an   empty 

Q 


226  DISEASES    OF    THE    KIDNEY. 

stomach,  the  ejected  matters  being  watery,  and  often 
alkaline  in  reaction  ;  (b)  ia  some  cases  the  vomiting 
seems  to  arise  from  gastric  catarrh,  consequent  npon  cir- 
rhosis of  the  liver,  which  according  to  the  statistics  of 
Grainger  Stewart  and  Murchison  is  present  in  about  fifteen 
per  cent,  of  the  cases  of  contracted  kidney.  Cirrhosis  of 
the  liver  may,  however,  be  accompanied  by  albuminuria, 
without  there  being  any  disease  of  the  kidney,  owing  to 
the  pressure  on  the  renal  veins  of  a  large  quantity  of 
fluid  in  the  peritoneum  (ascites),  when  this  is  removed  by 
tapping,  the  albumin  will,  if  there  be  no  actual  disease 
of  the  kidney,  speedily  disappear.  In  these  cases 
there  are  marked  dyspeptic  symptoms  after  taking  food. 
In  addition  to  the  ordinary  dyspeptic  pains,  a  severe 
gnawing  radiating  pain,  occurring  often  at  night  or  early 
morning,  is  often  experienced  in  the  hypochondriac  and 
epigastric  regions,  apparently  of  a  neurotic  character, 
which  coming  on  suddenly,  will  annoy  the  patient  for 
several  hours.  It  must  not  be  forgotten  that  owing  to  the 
CO- existence  of  hepatic  cirrhosis,  ascites  may  be  present, 
and  consequent  on  that,  some  degree  of  oedema  of  the 
legs.  Diarrhoea,  towards  the  close,  especially  when  there 
is  hepatic  disease,  is  a  very  troublesome  symptom,  the 
evacuations  being  usually  extremely  fluid  and  frequent. 

Eespkation  is  often  disturbed  by  attacks  of  dyspnoea, 
closely  resembling  nervous  asthma,  and  which  no  doubt 
are  caused  by  the  circulation  of  blood  poisoned  with  urea 
through  the  respiratory  nerve  centres.  The  attacks  come 
on  suddenly,  especially  during  the  night,  and  after  lasting 
some  hours  usually  subside  ;  patients  who  are  subject  to 
these  attacks  of  "  renal  "  asthma,  are  however  rarely  quite 
free  from  general  dyspnoea.  Sufferers  from  this  form  of 
chronic  kidney  disease  are  especially  liable  to  bronchitis 
and  pneumonia,   and  those  patients  who  insist  or  are 


CHRONIC   INTERSTITIAL    NEPHRITIS. 


227 


obliged  to  spend  their  winters  in  London,  or  in  unsuitable 
situations  in  England,  are  consequently  a  source  of  per- 
petual anxiety  to  their  medical  attendant. 

61.  Etiology. — In  a  disease  which  commences  so  insi- 
diously it  is  difficult  to  distinguish  closely  between  exciting 
and  predisposing  causes.  Among  the  latter,  age,  heredity, 
and  residence  in  damp  and  cold  climates,  seem  to  be  the 
most  prominent;  whilst  gout,  saturation  of  the  system  with 
lead,  chronic  dyspepsia  attended  with  frequent  deposits  in 
the  urine  of  oxalate  of  Ume  and  urates,  and  long-standing 
disease  of  the  genito- urinary  passages,  must  be  reckoned 
as  among  the  chief  exciting  causes. 

Age. — Many  have  asserted  that  interstitial  nephritis  is 
essentially  a  disease  of  old  age,  this,  however,  is  not  borne 
out  by  statistics,  which  unmistakably  show  that  it  is  a 
disease  of  later  middle  age,  rather  than  of  old  age, 
and  that  more  cases  occur  in  the  decade  between  fifty 
and  sixty  than  between  sixty  and  seventy,  whilst  the 
percentage  of  cases  met  with  between  forty  and  fifty  is 
shghtly  more  than  between  fifty  and  sixty.  In  the  earher 
years  of  hfe,  instances  of  the  disease  though  rare  are  to 
be  met  with.  Bartels  {op.  cit.),  out  of  thirty-three  cases 
examined,  met  with  four  instances  (or  eight  per  cent.)  of 
the  disease  under  twenty  years  of  age.  Taking,  however, 
the  statistics  of  various  authors,  the  following  table  gives 
probably  more  correctly  the  general  percentage. 


Under      20        years 
Between  20-30 

30-40 

40-60 

50-60 
Over         70 


1-5  per  cent. 

9 
21 
32 
28 
15 


The  youngest  case  I  have  observed,  was  twenty  years  of 

q2 


228  DISEASES    OF    THE    KIDNEY. 

age,  though  from  his  history  he  most  probably  had  been 
suffering  from  the  disease  for  some  two  or  three  years 
previously.  In  this  case  the  disease  was  not  the  result  of 
scailet  fever,  which  some  authors  are  disposed  to  think  is 
the  cause  of  interstitial  nephritis,  when  it  occurs  in  the 
young,  but  was  evidently  an  hereditary  tendency. 

The  disease  is  undoubtedly  more  common  in  men  than 
in  women,  in  England  it  is  said  to  be  twice  as  frequent, 
but  I  feel  disposed  from  my  own  observations  to  agree  with 
Bartels,  and  put  it  at  a  higher  figure,  say  4:1.  This  fre- 
quency is  no  doubt  accounted  for  by  the  fact  that  men  are 
more  hable  to  vesical  and  urethral  troubles  which  are  potent 
factors  in  the  etiology  of  the  disease. 

Bartels  observes  that  "  his  experience  does  not  enable 
him  to  accuse  any  particular  caUing  or  occupation  as 
predisposing  to  this  affection."  In  this  I  cannot  agree 
for  according  to  my  experience,  the  disease  is  more 
common  among  the  well  to  do,  highly  fed,  and  seden- 
tary members  of  the  community,  than  among  the  work- 
ing classes.  I  certainly  see  more  of  this  form  of  chronic 
Bright' s  disease  among  private  patients  than  in  the 
out-patient  dej^artment  of  the  Hospital,  whilst  with  the 
chronic  tubal  form,  the  reverse  obtains.  Again  too  with 
regard  to  particular  callings,  we  must  not  overlook  the 
frequent  occurrence  of  the  disease  among  workers  in  white 
lead.  The  question,  too,  how  far  alcohol  habitually  taken 
in  excess  tends  to  induce  the  disease,  has  been  much  dis- 
puted. The  general  consensus  of  opinion  of  late  years, 
has  been  quite  in  accord  with  the  views  expressed  by  Dr. 
Dickinson,  that  it  has  no  direct  effect.  Combined  however 
with  other  conditions,  especially  high  feeding,  and  sedentary 
habits,  it  no  doubt  plays  an  important  part  in  the  causation 
of  the  disease. 

Syphilis  undoubtedly  acts  as  a  cause  predisposing  to  inter- 


CHRONIC    INTERSTITIAL    NEPHRITIS.  229 

stitial  nephritis,  but  no  such  direct  relationship  seems  to 
exist  between  the  two  as  is  often  observed  in  the  sub-acute 
form  of  nephritis.  When  interstitial  nephritis  occurs  in  a 
syphilized  subject,  the  gravity  of  both  diseases  is  increased, 
and  degenerative  changes  in  the  vessels  usually  proceed 
with  great  rapidity. 

Cold  especially  residence  on  damp  cold  soils,  and  in 
marshy  and  malarious  districts,  undoubtedly  has  a  ten- 
dency to  induce  the  disease,  though  the  action  cannot  be 
traced  so  directly  as  in  chronic  tubal  nephritis.  In  that 
disease  I  stated,  that  I  believed  the  cases  said  to  follow 
attacks  of  intermittent  fever,  were  to  be  attributed 
rather  to  "cold  catching"  from  the  damp  situation  of 
the  residence,  than  to  the  influence  of  malaria.  In 
this  form  of  chronic  nephritis,  I  believe  long- continued 
malarial  poisoning  to  be  a  direct  cause,  probably  from  the 
paroxysms  causing  frequent  renal  hypersemia.  ■  In  all 
cases  that  have  come  under  observation,  several  years 
have  intervened  between  the  first  attack  of  intermittent 
fever,  and  the  discovery  of  the  renal  mischief. 

Heredity. — Some  very  remarkable  instances  proving  the 
tendency  to  hereditary  transmission  of  the  disease  have 
been  brought  forward  by  many  observers.  Dr.  Kidd  in 
the  twenty-ninth  volume  of  the  Practitioner,  has  contri- 
buted a  very  interesting  paper  on  this  subject ;  but  Dr. 
Dickinson's  account  of  eighteen  cases,  occurring  in  one 
family  within  three  generations,  with  a  very  strong  possi- 
bility that  the  disease  had  existed  in  the  family  for  some 
generations  before,  must  be  considered  the  best  and  most 
conclusive  evidence  that  can  be  quoted  on  this  point.  A 
gentleman,  who  I  saw  some  few  years  since,  informed  me 
that  four  of  his  brothers  had  died  of  renal  disease,  all  very 
nearly  at  the  same  age.  He  was  the  youngest  of  the 
family,  and  he  was  dreading  the  approach  of  the  fatal 


230  •      DISEASES    OF    THE    KIDNEY. 

period,  as  he  was  suffering  from  premonitory  symptoms, 
ursemic  headaches,  polyuria,  etc.  I  subsequently  learnt 
that  he  died  two  years  after  I  had  seen  him,  suddenly 
of  apoplexy.  In  this  case  the  father  had  died  with  cere- 
bral symptoms  about  the  same  age  that  had  proved  fatal 
to  five  of  his  sons. 

Gout. — The  gouty  kidney  is  essentially  the  result  of 
chronic  interstitial  change.  Professor  Virchow  {Berl.  Klin. 
Wochenschrift,  No.  I.,  1884)  states  he  has  never  seen  an 
acute  nephritis,  which  from  the  presence  of  uratic  deposit 
could  be  referred  to  gout.  The  albuminuria  which  is  often 
observed  in  connection  with  acute  attacks  of  gout,  is  rather 
to  be  referred  to  direct  irritation  of  the  whole  urinary 
tract,  the  renal  pelvis,  the  bladder,  prostate,  etc.  Pro- 
fessor Virchow  in  the  above-mentioned  communication  has 
related  his  own  personal  experience.  In  1882  he  had 
sHght  swelling  of  his  fingers,  and  shortly  afterwards  began 
to  suffer  from  irritable  bladder,  examination  of  the  urine 
showed  the  presence  of  pus  and  albumin,  on  adding  acetic 
acid  to  the  purulent  deposit,  uric  acid  crystals  separated  out 
to  an  extent  he  had  never  seen  before.  He  at  once  began 
taking  alkalies,  (sodium  biborate)  and  the  uric  acid  at 
once  disappeared,  and  with  it  the  pus  and  albumin.  He 
attributed  the  attack  to  the  irritating  effect  of  the  uric 
acid  exciting  a  purulent  catarrh  of  the  whole  urinary 
tract,  which  subsided  as  soon  as  the  irritant  was  with- 
drawn. The  "  gouty  kidney  "  is  distinguished  from  sim- 
ple interstitial  nephritis,  by  the  deposit  of  sodium  urate  in 
the  tubules,  in  addition  to  the  puckered  and  wasted  condi- 
tion of  the  cortex.  But  as  Professor  Virchow  has  pointed 
•out,  the  chronic  inflammatory  change  begins  in  the  cortex, 
at  a  distance  from  the  seat  of  the  deposit  of  urates  in  the 
tubes  iust  as  in  the  joints,  the  urates  occur  in  the  car- 
tilage and  ligaments,  whilst  the  synovial  membrane  is  the 


CHRONIC    INTERSTITIAIi    NEPHRITIS.  231 

seat  of  the  inflammation),  and  from  this  he  argues  that  it 
is  not  the  presence  of  the  deposit  in  the  tubules,  but  the 
exudation  of  the  fluid  containing  the  uric  acid  in  solution, 
that  acts  as  the  irritant.  According  to  this  view,  inter- 
stitial nephritis  is  the  primary  step  in  the  process,  and 
the  streaky  deposit  in  the  tubules  a  secondary  result. 
Whatever  the  process  may  be,  the  "  gouty  kidney  "  is 
slowly  evolved,  and  till  the  later  stages  gives  rise  to  no 
marked  symptoms.  No  relationship  exists  between  the 
degree  of  renal  affection  present,  and  the  amount  of  to- 
phaceous deposit  in  the  joints,  indeed  the  "  gouty  kidney" 
may  be  met  with  without  their  having  ever  been  any  acute 
manifestations  of  gout  at  all.  From  this  it  has  been 
argued  that  the  renal  affection  is  the  first  step  in  the  pro- 
cess, and  it  is  not  till  the  arrest  of  the  function  of  the  kid- 
ney, in  excreting  uric  acid  and  its  retention  in  the  blood, 
that  acute  manifestations  of  gouty  paroxysms  occur. 
There  are  objections  to  this  view  however,  and  it  is  more 
probable  that  the  deposit  of  urates  in  the  tubules  is  part  of 
the  process  which  leads  to  the  non- destruction  and  reten- 
tion of  uric  acid  in  other  parts  of  the  body  (see  Lithuria). 
Lead,  when  taken  into  the  system,  is  eliminated  chiefly 
by  the  kidneys.  Ollivier  (op.  cit.)  has  shown  that  given 
in  large  doses,  so  as  rapidly  to  induce  plumbism,  it  occa- 
sionally induces  acute  or  sub-acute  nephritis,  showing  that 
the  mineral  is  capable  under  certain  circumstances  of  pro- 
ducing renal  hyperemia.  But  the  most  frequent  form 
of  kidney  disease  met  with  in  connection  with  lead  poi- 
soning is  interstitial  nephritis.  Dickinson  {op.  cit.)  has 
shown  from  statistics  compiled  from  the  post-mortem  books 
of  St.  George's  Hospital,  that  out  of  forty-two  workmen 
engaged  in  some  form  or  other,  in  occupations  which 
brought  them  in  contact  with  lead,  twenty-six  had  granu- 
lar degeneration  of  the  kidney.     The  relationship  between 


232  DISEASES    OF    THE    KIDNEY. 

chronic  plumbism  and  gout  is  equally  well  marked. 
Garrod  has  shown  most  conclusively,  that  the  subjects  of 
lead  poisoning  frequently  become  gouty,  whilst  the  inheri- 
tors of  the  gouty  diathesis  are  extremely  susceptible  to  the 
influence  of  lead.  There  is  a  difference  of  opinion  how- 
ever, whether  the  renal  affection  depends  on  the  lead  or 
on  the  gout  for  its  development.  Some  writers,  chiefly 
German,  have  denied  the  direct  interdependence  between 
lead  poisoning  and  the  development  of  renal  disease, 
whilst  in  England  it  is  generally  assumed  that  the  first 
step  in  the  process  is  the  diminution  of  the  excretion  of 
uric  acid.  That  this  takes  place,  Garrod  [Treatise  on 
Gout,  3rd  edit.),  has  shown  experimentally,  by  adminis- 
tering lead  in  small  doses  to  patients  in  hospital,  and  then 
estimating  the  excretion  of  uric  acid,  which  in  all  cases 
showed  an  immediate  and  considerable  diminution.  And 
to  this  diminution  of  excretion,  and  consequent  retention 
of  uric  acid  in  the  blood,  the  frequency  of  gout  in  satur- 
nine patients  is  generally  referred.  Still  undoubtedly 
we  meet  with  instances  from  time  to  time,  in  hospital 
practice,  of  lead- workers  suffering  from  chronic  albumin- 
uria, in  whom  whilst  living  we  are  unable  to  detect  any 
evidence  of  gout,  nor  post-mortem  do  we  find  stride  of  de- 
posited urates  in  the  renal  tubules,  though  the  kidneys  are 
granular.  The  two  processes,  however,  are  usually  as- 
sociated, and  when  that  is  the  case  the  progress  down  hill 
becomes  extremely  rapid. 

Chronic  dyspepsia,  attended  with  frequent  deposits  of 
oxalates  and  urates  in  the  urine,  is  undoubtedly  a  common 
cause  of  interstitial  nephritis.  Thus,  Murchison  (op.  cit.) 
regarded  "  lithsemia  "  arising  from  functional  derangement 
of  the  Uver,  as  one  of  the  first  links  in  the  chain  of  causes 
tending  to  produce  contracted  kidney ;  and  Johnson  {op. 
cit.)  has  always  maintained  that  the  proximate  cause  of 


CHRONIC    INTERSTITIAL    NEPHRITIS.  233 

chronic  renal  disease  depends  upon  a  morbid  condition  of 
the  blood,  and  that  the  vitiated  products,  the  result  of 
abnormal  digestion,  absorbed  into  the  blood,  were  to  be 
reckoned  among  the  chief  of  the  toxic  agencies  bringing 
about  the  condition.  Both  Murchison  and  Johnson,  there- 
fore, regarded  the  nephritis  in  these  cases  as  arising 
directly  from  the  morbid  condition  of  the  blood,  whereas  I 
am  inclined  to  the  opinion,  that  the  nephritis  is  provoked 
by  the  direct  irritation  caused  by  the  almost  constant  pas- 
sage through  the  tubules  of  the  urinary  deposits,  sepa- 
rated from  the  urine,  when  the  blood  is  thus  morbidly 
charged  with  effete  products.  In  cases  of  chronic  dys- 
pepsia, especially  that  form  associated  with  deposits  of 
oxalate  of  lime,  a  certain  amount  of  renal  catarrh  and 
pyelitis  can  always  be  demonstrated  by  the  presence  of 
pus  cells,  and  epithelium  from  the  upper  urinary  tract. 
A  catarrh  that  subsides  when  means  are  taken  to  keep  the 
urine  sufficiently  dilute,  although  the  dyspeptic  symptoms 
remain.  Indeed  it  is  only  reasonable  to  suppose  that  the 
constant  passage  of  irritating  particles  of  oxalate  of  lime,  or 
of  urates,  along  the  tubules,  should  give  rise  to  chronic  ir- 
ritation, which  ultimately  brings  about  interstitial  changes, 
just  as  we  find  the  lungs  of  those  persons,  whose  occupa- 
tion exposes  them  to  the  inhalation  of  irritating  particles 
of  dust,  etc.,  become  affected  with  interstitial  pneumonia. 

Chronic  pyelitis  and  cystitis  certainly  must  be  regarded 
as  one  of  the  most  frequent  causes,  leading  to  interstitial 
changes  in  the  kidney.  In  the  cases  of  calculous  pyelitis, 
and  chronic  vesical  trouble,  which  have  eventually  proved 
fatal,  interstitial  changes  are  usually  observed,  and  though 
perhaps  in  some  the  macroscopic  appearances  are  not 
well  marked,  still  a  careful  microscopic  examination 
rarely  fails  to  reveal  interstitial  change.  Both  'pregnancy 
and  valvular  disease  of  the  heart  have  been  assigned  as  causes 


234  DISEASES    OF    THE    KIDNEY. 

of  interstitial  nephritis.  The  former,  however,  undoubtedly 
is  more  concerned  with  the  production  of  clironic  tubal 
nephritis,  and  when  a  granular  condition  of  the  kidney  is 
met  with,  the  history  is  such  as  to  enable  us  to  arrive  at  the 
conclusion  that  the  contraction  is  due  to  secondary  atrophy. 
In  valvular  disease  of  the  heart,  the  condition  of  kidney 
resulting  from  long- continued  venous  congestion,  is 
generally  described  as  the  cyanotic  or  indurated  kidney, 
and  differs  in  many  respects  from  the  kidney,  the  result  of 
interstitial  nephritis  properly  so-called.  An  account  of 
the  cyanotic  induration  of  the  kidney,  the  result  of  pas- 
sive venous  congestion,  is  given  in  the  section  on  the 
etiological  varieties  of  chronic  nephritis. 

62.  Prognosis. — As  regards  the  ultimate  issue,  the 
prognosis  must  always  be  unfavourable,  though  when  the 
affection  is  early  recognised,  and  the  patient  placed  under 
the  best  hygienic  conditions  and  dietetic  regulations,  the 
progress  of  the  disease  may  be  so  controlled,  that  its  ad- 
vance is  often  arrested  for  a  considerable  period.  Patients 
who  come  under  observation  complaining  of  debility  and 
general  malaise,  and  in  whose  urine  no  traces  of  albumin 
can  as  yet  be  discovered,  though  the  secretion  is  consider- 
ably increased,  and  the  urinary  solids  diminished,  rapidly 
improve  in  health,  even  if  they  do  not  entirely  regain  their 
former  robust  appearance,  after  they  have  been  placed  on 
a  regulated  diet,  and  under  favourable  hygienic  conditions, 
but  who  relapse  as  soon  as  they  neglect  these  measures, 
and  again  become  polyuric,  weak  and  debilitated.  Even 
when  the  disease  is  more  advanced,  life  may  be  prolonged, 
for  many  years,  when  the  patient  is  careful  to  carry  out 
the  instructions  of  the  medical  attendant.  Life  too  may 
be  prolonged  for  a  considerable  time,  even  after  the 
onset  of  ur^emie  convulsions.  Even  after  hasmorrHage 
from  the  cerebral  vessels  has  occurred,  the  prognosis  need 


CHRONIC    INTERSTITIAL    NEPHRITIS.  235 

not  be  considered  immediately  in  its  gravest  aspect,  as 
undoubtedly  many  recover,  more  or  less  completely,  from 
the  results  of  the  cerebral  lesion,  and  may  live  for  some 
years  after  the  event.  At  the  same  time  it  must  be  borne 
in  mind  that  the  improvement  which  may  set  in  after 
such  grave  events,  as  ursemic  convulsions,  or  cerebral 
apoplexy,  is  often  more  apparent  than  real,  and  is  only  the 
result  of  the  enforced  rest,  and  increased  care  and  atten- 
tion, bestowed  on  the  management  of  the  renal  trouble. 
In  many  instances,  this  has  been  developing  insidiously 
and  unsuspected,  and  the  uremic  convulsion,  or  the 
retinitis,  or  the  apoplexy,  are  the  first  symptoms,  that 
call  attention  to  the  fact.  The  treatment  that  follows, 
relieves  these  urgent  symptoms,  and  prevents  for  a 
time  their  recurrence,  and  though  it  fails  to  arrest 
the  slow  process  of  contraction  going  on  in  the  renal 
tissue,  it  undoubtedly  retards  it.  In  giving  an  opinion 
of  an  individual  case,  the  following  considerations 
may  help  us  to  form  an  estimate  of  the  future.  1.  In 
gouty  patients,  the  chronic  nephritis  is  slowly  evolved,  and 
generally  runs  a  prolonged  course.  2.  When  associated 
with  other  diseases,  such  as  syphihs,  struma,  general 
cirrhosis,  etc.,  the  disease  often  proves  fatal,  even  before 
extreme  contraction  of  the  kidney  takes  place,  from  the 
early  degeneration  of  the  vascular  system.  3.  The  most 
fatal  combination  is  perhaps  that  of  gout  with  chronic  lead 
poisoning.  4.  The  steady  persistence  of  ursemic  symp- 
toms, such  as  headache,  twitching  of  the  muscles,  morning 
vomiting,  etc.,  after  treatment  has  been  adopted,  must  be 
considered  more  ominous  than  a  decided  attack  of  severe 
convulsions.  The  latter  may  be  induced  by  accident  or 
some  sudden  compUcation  arising,  and  if  the  crisis  can  be 
surmounted,  life  may  still  be  prolonged ;  the  former,  on 
the  other  hand,  announces  that  the  disease  in  spite  of 


236  DISEASES    OF    THE    KIDNEY. 

remedial  measures,   is  steadily  advancing  from  bad  to 
worse. 

63.  Diagnosis. — There  is  little  difficulty  when  the  case 
is  fully  developed  and  is  under  continuous  observation. 
The  other  renal  affections,  it  may  be  taken  for,  are  the 
small  atrophied  kidney  of  chronic  tubal  nephritis,  and  the 
waxy  or  lardaceous  kidney.  From  the  large  white  kidney 
it  is  distinguished  by  characters  so  marked  that  a  mistake 
one  would  think  could  hardly  possibly  be  made.  The  dis- 
tinguishing symptoms  of  each,  which  we  have  already  des- 
cribed, being  as  the  following  table  shows  in  strong  contrast. 

Chronic  Tubal  Nephritis.         Chronic  InterstitialNephritis. 

j4fife,  more  frequent  in  youth  and  Age,     more    frequent    in    later 

early  middle  age.  middle  life. 

Developes  rsLTpidly;  from  two  to  Bevelopes  slowly j  from  four  to 

six  months.  five  years  or  more. 

Chief    Symptoms. — Dropsy    af-  Chief  Symptoms. — Hypertrophy 

fecting  the  whole  body  and  serous  of  left  ventricle,  albuminuric  reti- 

cavities.  Ursemic  convulsions  rare,  nitis,  atheroma  of  arteries,  ursemic 

as  also   albuminuric  retinitis  and  convulsions ;    oedema  only    slight 

haemorrhage.  and  towards  the  end. 

Urine     scanty,     high     specific  Urine    abundant,    low    specific 

gravity,     much    albumin.       Oasts  gravity,  little  albumin.  Casts,  hya- 

broad  hyaline,  granular,  and  waxy.  line  narrow,  dotted  with  oil  drops ; 

Deposit,  chiefly  urates,  and  granu-  with  fine  crystals  of  calcium  oxa- 

lar  debris.  late  sometimes  adhering.    Deposit 

chiefly  oxalate  of  Hme. 

The  contrast,  however,  between  the  symptoms  attendant 
on  the  atrophied  granular  kidney,  the  result  of  secondary 
changes  in  the  large  white  kidney,  and  the  symptoms 
associated  with  the  granular  kidney,  the  result  of  true  in- 
terstitial nephritis,  is  not  so  clearly  marked ;  indeed,  the 
symptoms  have  a  close  correspondence,  and  here  we  have 
to  depend  chiefly  on  the  history  of  the  case.  If,  therefore, 
we   have   a   history  of  long-standing  dropsy,  or  dropsy 


CHRONIC    INTERSTITIAL    NEPHRITIS.  237 

coming  on  quite  early  in  the  illness,  we  may  assume  that 
the  disease  is  not  primarily  due  to  intei'stitial  nephritis 
but  must  have  passed  through  the  phase  of  large  white 
kidney.  The  cardiac  hypertrophy  moreover  is  never  so 
completely  developed  in  the  secondary,  as  in  the  primary 
contracted  kidney.  Again,  although  the  urine  in  both 
forms  is  increased  in  quantity,  and  the  amount  of  albumin 
is  small,  still  the  amount  of  urine  seldom  reaches  the 
same  considerable  amount,  and  the  albumin  is  rarely  as 
scanty  in  the  secondary  contracted  kidney  as  in  inter- 
stitial nephritis,  whilst  an  attentive  examination  of  the 
deposit  shows  that  casts  are  more  abundantly  de- 
posited from  the  urine  in  the  former  condition,  and 
differ  from  the  latter  by  many  being  broad,  opaque, 
and  sometimes  mingled  with  highly  refracting  waxy 
casts.  Lardaceous  degeneration  of  the  kidney  may 
be  taken  for  contracted  kidney,  especially  in  those  cases 
in  which  the  urine  is  abundant  and  of  low  specific 
gravity,  and  the  amount  of  albumin  small,  and  the  easts 
scanty  and  chiefly  hyaline.  In  lardaceous  degeneration, 
however,  the  heart  is  not  hypertrophied,  and  we  generally 
have  the  history  of  long-continued  suppuration,  etc.,  and 
consequent  cachexia  to  direct  our  attention  to  the  true 
state  of  things.  Besides  which,  waxy  degeneration  of  the 
kidneys  is  the  only  condition  in  which  dropsy  and  polyuria 
are  found  associated  together. 

64.  Morbid  Anatomy. — Chronic  interstitial  nephritis 
results  in  what  is  known  as  the  small  red  granular  kid- 
ney. Variations  from  this  type  may  be  met  with,  as  for 
instance,  in  the  so-called  large  red  kidney,  probably  an 
early  stage  of  the  disease  before  contraction  of  the  con- 
nective tissue,  in  which  the  kidney  instead  of  being 
dwindled  in  volume,  is  a  little  increased  in  size.  Or  the 
kidney  instead  of  being  of  a  reddish-brown,  is  of  a  greyish 


238  DISEASES    OF    THE    KIDNEY. 

hue,  and  the  granulations  coarse,  in  this  case  we  may  sus- 
pect that  to  the  chronic  interstitial  inflammation,  an  acute 
attack  has  at  some  time  been  superadded.  When  the  dis- 
ease is  fully  developed  we  find  the  kidneys  shrunken,  about 
half  their  size  may  be  taken  as  an  average  expression,  though 
they  may  be  found  dwindled  to  the  size  of  a  pigeon's  egg,  or 
walnut.  Though  both  participate  in  the  process,  they  are  not 
always  equally  affected.  The  capsule  is  thickened,  adhering 
firmly  to  the  surface  of  the  kidney,  and  on  removing  it  small 
portions  of  kidney  substance  tear  away  with  it  (fig.  24). 
On  section  the  kidney  cuts  firmly,  and  its  consistence  is 
toughened,  and  the  exposed  surface  of  the  cortex  is  seen 
covered  with  granulations,  from  the  size  of  a  millet  seed 
to  that  of  a  mustard  seed,  and  to  be  of  a  dark  reddish  hue 
(maroon),  which  colour  is  always  more  marked  in  the  de- 
pressions of  the  granulations,  than  on  their  surface.  Cysts 
usually  stud  the  surface,  in  size  they  vary  from  a  x^iu-head 
up  to  a  considerable  size.  Irregular  depressions  will  also 
be  often  observed  on  the  surface,  probably  caused  by  the 
rupture  or  absorption  of  some  former  cyst.  On  section  it 
will  be  found  that  the  wasting  of  the  organ  occurs  chiefly 
in  the  cortical  portion,  though  the  pyramidal  is  also  con- 
siderably affected.  The  cut  surface  has  a  granular  ap- 
pearance, and  the  radiating  lines  of  the  cones  are  blurred. 
The  Malpighian  corpuscles  stand  out  as  red  points,  and 
cysts  are  usually  abundantly  met  with  throughout  the 
organ.  The  first  stage  in  the  process  consists  of  a  cellular 
infiltration,  which  commences  around  the  blood  vessels, 
and  the  capsule  of  the  Malpighian  corpuscles,  and  ulti- 
mately becoming  more  diffused,  and  spreading  inwards, 
involves  the  inter-tubular  connective  tissue.  This  process 
resembles  that  which  occurs  in  glomerulo  nephritis,  and 
which  has  been  described  at  p.  194  (fig.  21),  only  the  evolu- 
tion is  much  slower,  and  the  cells  are  not  so  numerous. 


CHRONIC   INTERSTITIAL    NEPHRITIS. 


239 


The  cellular  infiltration  of  the  inter- tubular  connective  tis- 
sue is  shown  (fig.  25).  The  new  growth  is  gradually  trans- 
formed into  a  fibrillated  structure,  which  more  or  less 
slowly  contracts,  and  compresses  the  capillaries,  and  the 
cajjsular  bodies,  so  at  last  many  of  the  glomeruli  become 
shrunken  to  mere  fibrous  knots.  The  cellular  infiltration, 
which  commences  round  the  interlobular  vessels,  and 
spreads  rapidly  into  the  bases  of  the  pyramids,  and  around 
the  convoluted  tubules  in  the  cortex,  also  undergoes  con- 
version into  laminated  connective  tissue,  by  the  cicatricial 


Fig.  25. — Early  stage  showing  cellular  infiltration  of  the  intertubular 
connective  tissue.  The  epithelium  has  fallen  out  of  some  of  the  tubes 
in  the  preparation  of  the  section  (Green's  Pathology). 

contraction  of  which  the  tubular  structures  undergo 
atrophy.  The  second  stage  in  the  process  is  character- 
ised by  changes  in  the  tubules.  Cloudy  swelling  of  the 
epithelium,  followed  by  desquamation  and  disintegration, 
and  whilst  many  of  the  tubes  are  completely  obhterated 
by  the    pressure    of    the    cicatricial    tissue,    others    are 


240  DISEASES    OF    THE    KIDNEY. 

only  diminished  in  size,  whilst  some  are  irregularly  di- 
lated, and  filled  with  granular  and  fatty  debris.  The 
irregular  pressure  exercised  by  the  contracting  connec- 
tive tissue  gives  rise  to  cysts.  Some  of  which  appear 
to  be  developed  from  partially  dilated  and  compressed 
tubules,  their  contents  being  transformed  into  a  trans- 
parent gelatinous  mass.  Other  cysts  according  to  Klebs 
and  Grainger  Stewart,  appear  to  be  formed  from  dilata- 
tions of  the  Malpighian  corpuscles.  As  the  disease  ad- 
vances the  glomeruli  become  more  and  more  involved, 
and  converted  into  fibrous  knots,  and  the  obhteration 
and  atrophy  of  the  tubes  more  extensive  (fig.  26).  The 
small  arteries  become  thickened  and  undergo  changes  such 
as  are  described  at  p.  17. 

In  the  "gouty  kidney"  in  addition  to  these  changes, 
white  points  and  streaks  of  sodium  urate  are  to  be  seen 
upon  the  pyramidal  portion  of  the  kidney.  According 
to  Dr.  Garrod  {op.  cit.),  this  deposit  seems  to  be  im- 
bedded rather  in  the  fibrous  structure,  than  withia  the 
cavities  of  the  tubules.  Still  amorphous  and  partly 
crystalline  deposits  of  urate  sodium  are  to  be  found  in  the 
tubes.  These  consist  of  bundles  of  prismatic  needles 
arranged  longitudinally  in  the  direction  of  the  straight 
tubes  of  the  pyramids,  and  sometimes  the  tubes  are 
obstructed  by  cylindrical  masses  of  amorphous  urate. 

In  typical  cases  there  is  little  difficulty  in  distinguishing 
between  the  small  redgiranular  kidney,  the  result  of  chronic 
interstitial  inflammation,  and  the  small  contracted  kidney, 
which  is  produced  by  secondary  changes  in  the  large  white 
kidney.  But  if  it  happens  that  the  small  red  kidney  be- 
comes the  seat  of  acute  inflammation,  or  the  period  of 
secondary  contraction  is  prolonged,  intermediate  forms 
will  be  produced,  so  that  it  becomes  very  difficult  to  dis- 
tinguish clearly  between  them.      In  the  former  case  the 


CHRONIC    INTERSTITIAL    NEPHRITIS. 


241 


.    ^y 


Fig.  26.  —Granular  contracted  kidney.     Segment  of  the  cortex  seen  under  a 
low  power  (1  inch),  showing  a  somewhat  conical  patch  of  disease. 

a.  Region  of  convoluted  tubes,  occupied  by  an  apparently  fibrous  tissue,  com- 
posed to  a  large  extent  of  atrophied  tubes. 

a'.  Denser  fibrous  tissue  in  deeper  part  of  cortex. 

b.  Atrophied  glomeruli,  with  thickened  capsule  and  remains  of  the   capillary 
tuft. 

h' .  Other  atrophied  glomeruli,  completely  transformed  into  masses  of  concen- 
tric fibrous  tissue. 

c.  A  glomerulus  persisting,  without  obvious  morbid  change. 
(Z.  Thickened  vessels. 

e-  Convoluted  tubules  in  surrounding  tract,  somewhat  dilated. 
/.  Colloid  casts  in  these  tubules.     (Prof.  Greenfield,  Patli.  Soc.  Trans.,  vol. 
xxxi.). 

K 


242  DISEASES    OF    THE    KIDNEY. 

characteristic  red  colour  of  the  typical  interstitial  kidney  is 
less  marked,  and  the  organ  assumes  more  of  a  greyish- 
yellow  or  buff  colour  from  the  infiltration  of  fat,  the  result 
of  the  more  acute  process.  On  the  other  hand,  when 
the  process  of  secondary  contraction  is  unduly  prolonged, 
the  kidney  loses  its  white  colour,  and  acquires  more  of  a 
buff  or  reddish  grey  colour,  this  change  of  colour  being 
accounted  for  by  the  gradual  removal  and  absorption  of 
the  infiltrated  fat,  and  also  from  the  increased  vascularity 
of  the  superficial  vessels.  In  forming  an  opinion  in  either 
of  these  cases,  we  are  of  course  greatly  helped  by  a  con- 
sideration of  the  history  of  the  case,  but  even  in  the  ab- 
sence of  this  important  particular,  I  think  we  may  often 
form  an  opinion  from  the  general  appearance  of  the  kid- 
ney itself,  since  it  is  rare  for  kidneys,  the  subjects  of 
secondary  atrophy  to  undergo  such  a  degree  of  contraction 
and  dwindling,  as  occurs  when  the  chronic  inflammation 
is  primary.  Again,  whilst  the  surface  of  the  kidney  in 
chronic  interstitial  nephritis  is  finely,  or  at  the  most 
coarsely,  granular  (fig.  24),  in  the  secondary  atrophy 
following  on  chronic  tubal  nephritis,  the  organ  appears 
to  be  deeply  lobulated,  and  has  a  nodular  rather  than  a 
granular  appearance  (fig.  23). 


Etiological  Varieties  of  Nepheitis. 

65.  Scarlet  fever  nephritis  at  first  claims  attention. 
It  arises  during  the  desquamation  of  skin  after  the  sub- 
sidence of  the  acute  attack,  generally  in  the  third  week, 
and  rarely  before  the  eighteenth  day  of  the  disease.  Dr. 
Mahomed  has  stated  that  it  is  preceded  by  increased  tension 
of  the  pulse,  constipation,  the  presence  of  the  crystalloids 
of  the  blood  in  the  urine,  as  evidenced  by  the  guaiacum 


SCAELET    FEVER    NEPHEITIS.  243 

test.  Thongli  I  disagree  with  Dr.  Mahomed's  explanation 
of  the  cause  of  the  phenomena,  still  when  they  are  ob- 
served they  are  useful  indications  of  the  coming  storm, 
and  enable  us  to  take  precautionary  measures.  I  have 
also  observed  that  coincidently  with  the  coming  on  of  the 
albuminuria  the  urine  often  becomes  alkaline  from  fixed 
alkah,  whilst  crystals  of  triple  phosphate  speedily  form  in 
the  urine,  after  it  has  been  passed,  from  ammoniacal  de- 
composition. The  albuminuria  that  occurs  frequently 
during  the  early  stage  of  scarlet  fever  must  not  be  re- 
garded as  connected  with  scarlet  fever  nephritis.  The 
former  appears  during  the  acme  of  the  disease,  and  is  a 
true  pyrexial  albuminuria  which  disappears  as  the  temper- 
ature falls,  and  is  never  accompanied  with  dropsy ;  the 
latter  sets  in  only  during  the  subsidence  of  the  specific 
fever,  with  decided  evidence  of  renal  trouble,  and  usually 
accompanied  with  some  degree  of  dropsy.  In  favourable 
cases,  which  form  the  majority,  the  nephritis  subsides  in 
about  three  weeks  after  the  commencement  of  the  attack, 
and  at  the  end  of  six  weeks  or  two  months  the  urine  is 
found  generally  free  from  epithelium,  casts,  etc.,  though 
perhaps  a  trace  of  albumin  may  appear  in  the  urine  after 
exercise,  or  after  a  substantial  meal.  So  long  as  this  al- 
buminuria continues,  the  patient  must  be  kept  under 
medical  supervision.  In  aggravated  or  neglected  cases  the 
disease  may  drag  on  many  months,  dropsy  and  albumin- 
uria recurring  after  each  exposure  to  cold,  etc.,  till  finally 
the  disease  becomes  chronic,  and  the  stage  of  granular  kid- 
ney entered  upon.  The  frequency  with  which  nephritis 
follows  scarlet  fever  varies  in  different  epidemics,  and  by 
no  means  depends  on  the  severity  of  the  original  disease. 
Thus  I  have  seen  some  of  the  most  severe  cases  of  nephri- 
tis follow  on  only  slight  manifestations  of  scarlet  fever, 
whilst  some  severe  cases  have  escaped  nephritis  altogether. 

E  2 


244  DISKASES    OF    THE    KIDNEY. 

The  fatality  too  varies  in  different  epidemics,  and  I  believe 
is  much  influenced  by  the  sanitary  surroundings  of  the 
patients.  In  a  large  school,  thirty-six  boys  attacked  with 
scarlet  fever  came  under  my  observation,  of  these,  thhteen 
had  scarlet  fever  nephritis  ;  of  the  thirteen  only  two  had 
decided  dropsy,  though  in  each  case  some  slight  oedema  was 
present.  One  died  of  acute  uraemia  and  suppression  of 
urine,  this  case  had  had  scarlet  fever  so  slightly  that  it  had 
escaped  the  attention  of  those  responsible  for  sending  the 
boy  to  the  sick  infirmary,  and  he  was  still  at  his  studies 
when  attacked  with  convulsions.  In  twelve  of  the  cases 
in  which  the  commencement  of  the  disease  was  definitely 
determined,  albumin  first  appeared  in  the  urine  from  the 
seventeenth  to  the  twenty -first  day.  Since  scarlet  fever 
nephritis  stands  in  no  direct  relation  to  the  severity  of  the 
disease,  as  manifested  by  the  profuseness  of  the  rash  or 
ulceration  of  the  throat ;  whilst  the  theory  that  it  is  due 
to  checking  the  elimination  of  the  poison  through  the  skin 
owing  to  "cold  catching,"  seems  to  be  invalidated  by  what 
has  often  struck  me  very  forcibly,  that  the  proportion  of 
cases  of  nephritis  following  scarlet  fever  does  not  seem  to 
be  greater  in  the  houses  of  the  poor  where  the  nursing  is 
insufficient  and  the  children  sent  out  of  doors  as  soon  as 
convalescent,  than  among  the  rich  whose  children  are 
nursed  with  solicitude,  and  whose  convalescence  is  carefully 
attended  to.  The  question  therefore  arises,  to  what  is  the 
post- scarlatinal  renal  affection  due  ?  At  present  no  decided 
answer  can  be  given  to  this  question  (see  also  p.  181),  but 
the  discovery  of  bacteria  in  some  cases  of  scarlet  fever  and 
diphtheritic  nephritis  makes  it  probable,  that  these  organ- 
isms may  be  concerned  in  the  production  of  this  form 
of  nephritis,  a  supposition  rendered  all  the  more  probable 
by  Mr.  Cheyne's  experimental  observations  {Brit.  Med. 
Journal,  Sept.  24th,  1884),  who  found  that  when  bacteria 


PUERPERAIi    NEPHEITIS. 


245 


froin  cultivation  fluids  were  injected  into  the  blood  that 
they  were  mainly  eliminated  by  the  kidneys,  whose  tissues 
became  crowded  with  them.  With  regard  to  the  patholo- 
gical changes  that  occur  in  scarlet  fever  nephritis,  we  have 
already  seen  that  they  consist  primarily  and  mainly  in  an 
infiltration  of  nuclear  masses  within  the  capsule  of  the 
glomerulus  (glomerulo  nephritis),  and  that  the  changes  in 
the  tubules  are  the  second  step  in  the  process  ;  as  a  con- 
sequence we  find  therefore  in  quite  early  stages  the  kidney 
but  little  enlarged,  and  even  when  the  changes  in  the 
tubules  are  well  advanced,  the  kidneys  rarely  attain  the 
volume  found  in  catarrhal  nephritis  in  which  the  tubular 
changes  are  primary.  The  description  given  of  scarlet 
fever  nephritis  may  be  applied  to  acute  renal  inflamma- 
tion following  on,  diphtheria,  small-pox,  chicken-pox, 
measles,  typhus,  and  the  like. 

66.  Puerperal  nephritis.  — This  has  been  attri- 
buted by  some  writers  to  the  pressure  of  the  pregnant 
uterus  upon  the  renal  vessels,  others  believe  it  due  to  an 
altered  condition  of  the  blood.  With  regard  to  the  first 
view  I  must  confess  myself  on  anatomical  grounds  un- 
able to  accept  it,  for  I  cannot  see  how  the  pregnant 
uterus  can  compress  the  renal  veins.  Moreover,  clini- 
cally the  somewhat  profuse  albuminuria  of  pregnancy  is 
utterly  unlike  what  we  meet  with  in  obstructive  engorge- 
ment of  the  veins,  such  as  we  find  in  long  standing  heart 
disease,  and  which  leads  to  cyanotic  induration  of  the 
kidney,  whereas  the  symptoms  correspond  to  those  of  dif- 
fuse nephritis.  Nor  pathologically  do  we  find  evidence 
of  obstructive  engorgement,  for  if  we  examine  the  kidneys 
from  a  patient,  in  whom  the  disease  is  recent,  we  find  they 
do  not  differ  from  those  we  find  post-mortem  in  scarlet 
fever  nephritis  ;  whilst  when  the  disease  is  of  long-stand- 
ing, the  result  of  continued  pregnancies,  or  a  continua- 


246  DISEASES    OF    THE    KIDNEY. 

tion  of  the  original  attack,  the  kidneys  become  pale  and 
granular,  just  as  occurs  in  oft  repeated  or  long-continued 
attacks  of  sub- acute  nephritis,  and  never  assume  the 
peculiar  appearance  characteristic  of  venous  obstruc- 
tion. On  the  other  hand,  it  is  more  probable  that 
puerperal  nephritis  depends  upon  some  change  in  the 
blood,  during  pregnancy,  which  renders  the  secreting 
organs  liable  to  parenchymatous  changes,  for  we  find  of 
all  the  causes  of  acute  yellow  atrophy  of  the  liver,  the 
puerperal  state  stands  foremost  on  the  list.  Puerperal 
nephritis  is  said  to  occur  during  the  last  months  of  preg- 
nancy ;  it  would  be  more  accurate,  however,  to  state  that 
it  is  rarely  met  with  before  the  end  of  the  third  month,  and 
that  it  hardly  ever  developes  after  the  seventh  month. 
The  period  at  which  according  to  my  experience  nephritis 
usually  sets  in,  is  at  the  end  of  the  fourth  and  during  the 
whole  of  the  fifth  month,  from  then  I  think  the  tendency 
gradually  declines  till  the  time  for  delivery.  It  is  stated 
that  primiparse  are  more  liable  to  the  disease  than  women 
who  have  already  borne  children ;  this  statement,  however, 
requires  modification,  and  it  should  rather  be  that  women 
who  have  not  been  the  subject  of  nephritis  in  their  first 
pregnancy  are  less  liable  to  the  disease  in  subsequent 
pregnancies,  and  that  the  risk  is  diminished  with  each 
successive  pregnancy.  Nephritis  is  said  to  occur  in  one 
out  of  every  150  pregnancies.  This  may  accord  with  the 
experience  of  lying-in  hospitals,  who  are  called  upon  to 
attend  severe  cases  of  puerperal  eclampsia  and  dropsy, 
but  I  am  sure  the  proportion  is  far  too  high  as  regards 
the  general  run  of  practice.  I  would  here  distinguish 
between  the  albuminuria  frequently  met  with  in  pregnant 
women,  due  to  functional  derangement  (see  Chap.  XI.), 
and  the  albuminuria  of  nephritis,  accompanied  with 
dropsy  and  uraemic  convulsions. 


PUERPERAL    NEPHRITIS.  247 

The  course  of  puerperal  nephritis  usually  runs  a  sub- 
acute rather  than  an  acute  course.  The  disease  com- 
mences insidiously,  and  the  urine  which  is  diminished 
in  quantity  and  highly  albuminous,  rarely  contains 
blood,  and  as  a  rule  but  few  hyaline  casts.  In  some 
cases,  however,  the  onset  is  awfully  sudden  and  fou- 
droyant  in  character.  The  considerable  amount  of 
albumin  passed  in  this  form  of  nephritis  has  been  gene- 
rally remarked.  In  a  case  I  examined  for  Dr.  John 
Williams,  the  urine  of  twelve  hours  contained  5"1  grms. 
of  dry  coagulated  albumin,  which  for  the  whole  day  would 
represent  10  grms.,  a  very  considerable  quantity.  This 
high  degree  of  albuminuria  is  to  my  mind  an  additional 
evidence  of  an  altered  condition  of  the  blood  in  this  state. 
In  puerperal  nephritis  too,  sero-globulin  (paraglobulin)  is 
also  present  in  abundance,  often  in  absolute  excess  of  the 
serum  albumin,  this  probably  explains  the  high  grade  of 
the  albumiauria.  General  dropsy  to  a  greater  or  less  de- 
gree is  present  in  nearly  every  case  of  puerperal  nephritis. 
Whilst  ursemic  convulsions  of  an  acute  character  are 
present  in  about  25  per  cent,  of  the  cases  (Eosenstein) 
of  the  albuminuria  of  pregnancy.  The  uremic  convul- 
sions in  this  form  of  nephritis  are  particularly  severe  (puer- 
peral eclampsia),  and  often  accompanied  with  maniacal 
excitement  and  temporary  amaurosis.  The  reason  for 
the  special  intensity  of  the  ursemic  symptoms  in  puerperal 
nephritis  has  not  been  explained,  but  I  beheve  it  to  be  re- 
lated to  the  excessive  drain  of  albumin  from  the  blood 
leading  to  an  altered  percentage  relationship  between  the 
nutritive  and  effete  materials  of  that  fluid.  As  already 
stated  the  post-mortem  examination  of  the  kidneys,  shows 
them  to  have  been  the  seat  of  diffuse  nephritis.  In  some 
cases  severe  convulsions  occur  without  there  being  any 
evidence  of  albuminuria  or  dropsy  ;    in  these  cases,  I  be- 


248  DISEASES    OF    THE    KIDNEY. 

lieve  the  convulsions  are  purely  epileptic,  and  not  in  any 
way  connected  with  the  state  of  the  renal  organs.  In  cases 
when  the  disease  is  of  recent  origin  we  find  glomerular 
and  tubal  changes  in  progress,  sometimes  one  form  being 
more  marked  than  the  other.  As  a  rule  the  nephritis  ter- 
minates with  delivery,  but  in  some  instances  the  albumin- 
uria may  be  continued  to  the  next  pregnancy  when  an 
exacerbation  of  the  symptoms  occur,  or  even  if  the  patient 
recover  between  the  pregnancies,  the  frequent  recurrence 
of  the  nephritis  during  the  puerperal  state  leads  to  the 
estabhshment  of  chronic  nephritis,  and  the  development 
of  the  large  white  kidney,  and  in  process  of  time  to  the 
pale  granular,  or  atrophied  kidney. 

67.  Malarial  nephritis.— -In  this  country,  at  least, 
where  the  manifestations  of  the  malarial  poison  are  rarely 
intense,  the  form  of  nephritis  associated  with  impaludism 
that  most  frequently  comes  under  our  observation,  is  that  of 
purely  interstitial  nephritis,  whilst  the  cases  of  acute  or 
sub- acute  nephritis  occurring  in  persons  residing  in  damp 
and  marshy  districts,  which  are  sometimes  attributed  to 
ague,  are  in  reality  caused  by  the  long- continued  effects 
of  cold  and  damp.  In  countries,  however,  where  the  dis- 
ease assumes  an  intensity,  fortunately  now  unknown 
among  us,  structural  changes  of  an  acute  character  do 
undoubtedly  occur.  Dr.  Atkinson  (American  Jour.  Medical 
Sciences,  1884J,  in  a  valuable  contribution  on  the  subject, 
thinks  that  the  usual  form  of  malarial  nephritis  is  the  tubal 
and  diffuse,  and  that  this  inflammation  seems  to  be  most 
intense  in  the  vicinity  of  the  glomeruli.  Kiener  and  Kelsch 
(op.  cit.)  also  describe  a  haemoglobinuric  hypersemia  as  oc- 
curring during  severe  attacks  of  ague,  in  which  the  kidneys 
though  little  altered  in  size  and  weight  are  intensely  con- 
gested. The  cortex  obscured  by  haematic  coloration, 
whilst   the  glomeruli  stand  out  as  red    points,  and  the 


SATUENINE    NEPHEITIS.  249 

pyramids  of  brighter  red.  The  convohited  tubes  are  en- 
larged, and  the  epithelia  swollen  and  discoloured,  the  tubes 
full  of  casts.  The  glomeruli  are  dilated,  the  epithelia  of 
the  capsule  being  tumefied  and  granular,  and  small 
haemorrhages  often  occur  within  the  capsule.  The  inter- 
lobular veins  are  dilated  and  their  contents  generally 
thrombosed.     The  interstitial  tissue  is  but  little  modified. 

68.  Syphilitic  nephritis. — There  is  some  doubt 
whether  acute  nephritis  ever  developes  directly  in  con- 
nection with  syphilis.  The  albuminuria  often  met  with  in 
the  tertiary  stages  being  associated  with  waxy  degenera- 
tion of  the  kidneys  ;  and  though  nephritis  frequently 
supervenes  in  this  condition,  it  is  doubtful,  as  far  as 
syphilis  is  concerned,  whether  a  nephritis,  due  to  this  spe- 
cific cause,  ever  precedes  the  degenerative  changes.  It  is 
a  fact,  however,  that  albuminuria  does  sometimes  occur 
during  the  development  of  the  secondary  stage  of  syphilis  ; 
this  is  usually  the  case  when  the  invasion  is  attended  with 
considerable  constitutional  disturbance,  accompanied  by  a 
marked  rise  of  temperature,  and  abundant  roseolous 
eruption,  slight  jaundice  is  often  also  observable  in  such 
cases.  But  whether  this  albuminuria  is  due  to  parenchy- 
matous changes  dependent  upon  the  pyrexia,  or  whether  a 
true  nephritis  is  established  I  have  not  yet  been  able  to 
decide.  The  albuminuria  rapidly  subsides  on  the  adminis- 
tration of  anti- syphilitic  medicines.  Another  form  of 
albuminuria  occurs  in  syphilitic  patients  when  the  admin- 
istration of  mercury  has  been  too  long-continued,  or  in- 
judiciously administered  ;  on  the  withdrawal  of  the  drug, 
however,  the  albuminuria  speedily  disappears. 

69.  Saturnine  and  Gouty  nephritis Experiments 

on  animals  have  shown  that  the  administration  of  lead  salts 
in  large  doses  will  induce  an  acute  diffuse  nephritis  in  which 
the  changes  are  most  marked  in  the  vicinity  of  the  glomeruli. 


250  DISEASES    OF   THE    KIDNEY. 

But  the  form  of  kidney  we  meet  with  cHnically  is  essen- 
tially chronic  in  its  evolution  characterized  by  consider- 
able interstitial  changes  (see  also  p.  231).  So  also  with 
gouty  nephritis,  for  here  according  to  the  view  of  Professor 
Virchow  (see  p.  230)  chronic  interstitial  nephritis  is  the 
primary  step  in  the  process,  and  the  streaky  deposit  in  the 
tubules  the  secondary  result,  whilst  the  albuminuria  that 
sometimes  occurs  during  an  acute  attack  of  gout  is  not  to 
be  referred  to  acute  nephritis,  but  to  a  direct  irritation  of 
the  whole  urinary  tract. 

70.  The  Cyanotic  induration  of  the  Kidneys 
which  results  from  long-continued  venous  congestion  cannot 
be  regarded  as  a  true  nephritis,  though  at  one  time  included 
in  the  list  of  Bright's  diseases  of  the  kidney.  The  appear-' 
ance  of  the  kidney  differs  from  that  which  results  from 
chronic  interstitial  nephritis,  by  the  kidneys  being  a  little 
larger  than  they  should  be,  by  the  capsule  being  easily 
stripped  off  instead  of  being  more  or  less  adherent.  Also 
the  surface  is  smooth,  not  granular,  only  in  cases  in  which 
the  process  has  been  long  continued  are  there  shallow 
cicatricial  depressions.  The  surface  is  also  marked  by  stel- 
late groups  of  distended  venous  radicles.  On  section  the 
kidney  cuts  toughly,  and  both  cortical  and  medullary  sub- 
stances are  highly  vascular  and  deeply  coloured,  whilst  the 
Malpighian  tufts  are  not  particularly  distended,  the  vena 
recta  on  the  other  hand  are  the  seat  of  marked  engorgement. 
The  interstitial  tissue  is  thickened  and  tough,  but  the  accu- 
mulation of  lymphoid  cells  between  the  tubuli  is  rarely  ob- 
served, except  perhaps  in  cases  that  come  under  observation 
at  an  early  period,  but  they  are  never  so  marked  as  at  an 
early  stage  of  chronic  interstitial  nephritis.  The  epithe- 
lium is  at  first  unaltered,  but  as  the  disease  advances, 
owing  probably  to  want  of  proper  oxygenation,  from  the 
venous  stasis,  the  cells  undergo  degeneration,  become  fatty 


CYANOTIC    INDUKATION. 


251 


and  are  removed.  This  change  occurs  principally  in  the 
convoluted  portion  of  the  tubules,  and  causes  the  cortex  to 
assume  a  hghter  colour,  whilst  the  medullary  substance 
still  remains  deeply  cyanotic. 

This  condition  of  kidney  results  in  all  cases  of  long- 
standing obstruction  to  the  return  of  blood  by  the  inferior 
vena  cava,  it  consequently  follows  on  valvular  disease  of 
the  heart,  more  especially  in  the  mitral  obstructive  form ; 
in  all  cases  in  which  the  muscular  power  of  the  heart  is 
weakened,  such  as  occurs  in  dilatation  of  the  right  ven- 
tricle in  emphysema  ;  or  from  malnutrition  of  the  cardiac 
muscle.  The  albuminuria  of  heart  disease  can  be  dis- 
tinguished from  that  of  chronic  tubal  nephritis,  by  the 
fact  that  the  amount  of  albumin  in  the  urine  in  the  former 
is  extremely  small,  whilst  in  the  latter  it  is  always  fairly 
abundant ;  by  the  absence  from  the  former  of  granular 
and  epithelial  casts,  or  indeed  of  casts  of  all  kinds,  except 
perhaps  a  few  hyaline  ones,  to  which  a  few  epithelial  cells 
may  adhere  towards  the  end,  in  protracted  cases.  The 
dropsy  is  cardiac  not  renal  in  its  origin,  that  is  to  say,  it 
is  local,  being  confined  to  the  parts  that  are  drained  by  the 
inferior  vena  cava.  The  urine  is  scanty,  high  coloured, 
usually  extremely  acid,  and  with  a  specific  gravity  ranging 
often  as  high  as  1-035,  these  points  distinguish  cardiac 
albuminuria  from  that  of  chronic  interstitial  nephritis, 
whilst  it  is  rarely  associated  with  ursemic  symptoms,  which 
are  characteristic  of  the  latter. 

Teeatment  of  Nephritis. 

71.  In  acute  nephritis  it  should  be  borne  in  mind 
that  much  harm  may  be  caused  by  the  employment  of  a 
too  active  treatment,  especially  by  means  of  cathartics,  dia- 
phoretics and  diuretics.     In  ordinary  cases,  I  mean  those 


252  DISEASES    OF    THE     KIDNEY. 

unattended  with  complete  suppression  of  urine  and  acute 
uraemia,  it  will  be  sufficient  to  keep  the  patient  in  bed,  in 
a  moderately  warm  room  (60-65°  F).  The  bowels  if  con- 
fined should  be  opened,  but  all  violent  purgation  should 
be  avoided,  certainly  the  administration  of  hydragogues. 
I  usually  order  a  desert  spoonful  of  castor  oil,  and  if  this 
is  not  sufficient,  a  simple  enema  of  warm  water  is  thrown 
up  the  bowel,  about  four  hours  after,  to  aid  the  administra- 
tion of  the  oil.  As  the  bowels  have  a  tendency  to  constipa- 
tion throughout  the  illness,  they  must  be  kept  open  by  some 
simple  means.  For  this  purpose  "  imperial "  may  be  used, 
this  consists  of  adding  ^  oz.  of  bitartrate  of  potash  to 
a  quart  of  lemonade,  and  allowing  the  patient  to  drink 
from  time  to  time,  till  the  bowels  are  acted  upon.  The 
diet  should  be  light,  bland,  and  nutritious,  and  should  be 
chiefly  farinaceous,  albuminous  principles  being  reduced 
to  a  minimum,  eggs  being  forbidden  in  any  form.  In 
more  severe  forms,  in  which  ^the  secretion  of  urine  is 
suppressed,  or  very  nearly  so,  and  uremic  symptoms  have 
set  in  in  an  acute  form,  our  measures  must  be  more  active, 
though  here  recourse  to  powerful  purgatives,  diuretics  and 
the  like,  is  to  be  deprecated.  Our  endeavour,  in  these  cases, 
is  to  reduce  the  amount  of  nitrogen  in  the  blood,  firstly,  by 
cutting  off  the  supply,  secondly,  by  restoring  the  elimina- 
ting function  of  the  kidney.  To  fulfil  the  first  indication, 
the  patient  must  be  placed  on  a  rigorous  non-nitrogenous 
diet,  that  is,  no  albuminous  substance  whatever  is  to  be 
administered,  not  even  a  piece  of  toast  or  a  tea-spoonful  of 
milk.  Dr.  Aiifrecht  of  Magdeburg  (Berlin.  Klin.  Wochen- 
schrift,  Dec.  12th,  1883),  who  advocates  the  treatment  of 
acute  nephritis  by  this  system,  gives  the  details  of  a 
case  in  which  suppression  of  urine  lasted  for  eighty  hours, 
and  which  ultimately  recovered,  without  recourse  being 
had  to  any  other  mode  of  treatment.     Dr.  Aufrecht  ad- 


TREATMENT    OF    NEPHRITIS. 


253 


vises  a  rigid  abstinence  from  nitrogenous  food  of  all  kinds, 
even  milk,  till  after  the  second  week  of  the  attack.  In 
ordinary  cases  it  would  be  difficult  to  enforce  so  severe  a 
regimen,  which  practically  condemns  the  patient  to  arrow- 
root gruel,  though  the  benefit  attendant  on  such  a  diet  is 
great.  Therefore,  if  the  case  is  not  very  severe,  the  patient 
should  be  kept  on  an  absolute  non- nitrogenous  diet  for  two 
days  only,  and  then  allowed  a  slight  relaxation,  if  he  com- 
plains of  the  diet,  permitting  the  arrowroot  to  be  made  with  a 
little  milk,  or  some  rice  to  be  stewed  in  thin  broth,  or  plain 
rice  pudding  to  be  given.  No  solid  food,  flesh  or  fish  should 
be  given,  certainly  during  the  first  fortnight,  and  only  so 
much  milk  as  may  be  requisite  for  the  preparation  of  the 
farinaceous  articles  of  diet.  The  patient  may  eat  at  dis- 
cretion, the  wholesome  kinds  of  fruit,  grapes,  oranges, 
strawberries.  If  the  case  be  very  severe,  then  the  absolute 
non-nitrogenous  diet  must  be  continued.  Our  treatment 
has  also  often  to  be  directed  to  the  relief  of  complications 
that  may  arise,  such  as  suppression  of  urine,  followed  by 
uraemia,  and  dropsy. 

Uraemic  convulsions  in  acute  nephritis  are  usually  pre- 
ceded by  a  considerable,  if  not  complete,  diminution  in  the 
amount  of  urine  and  urea  excreted.  If  we  are  thus  fore- 
warned, we  may  by  the  judicious  administration  of  purga- 
tives and  the  vapour  bath  prevent  the  attack.  But  we  must, 
however,  be  careful  not  to  be  over  active ;  undoubtedly 
many  patients  have  been  hurried  into  an  attack  of  convul- 
sions, by  over  purgation  and  the  prolonged  action  of  the 
vapour  bath.  Kemember,  our  object  is  not  to  withdraw 
water  from  the  body,  and  so  proportionally  increase  the 
amount  of  extractives,  but  to  stimulate  the  secreting  organs, 
and  thus  ensure  the  elimination  of  urea  and  other  mat- 
ters that  have  accumulated  in  the  body.  Now  we  know 
that  urea  is,  under  certain  conditions,  eliminated  by  the 


254  DISEASES    OF    THE    KIDNEY. 

mucous  membrane  of  the  digestive  tract,  and  also  by  the 
skin,  and  that  by  the  latter  a  considerable  amount 
of  carbonic  acid  is  also  discharged.  Now  if  our  mea- 
sures are  too  active,  we  obtain  the  maximum  discharge 
of  water  both  by  bowels  and  skin,  and  the  minimum 
amount  of  relief  to  the  system  of  the  deleterious  agents  we 
seek  to  eliminate ;  whilst,  on  the  other  hand,  if  the  action 
is  more  gradual,  we  effect  our  object  without  the  with- 
drawal of  too  much  water.  For  purgation  in  these  cases, 
I  advise  the  administration  of  from  one  to  two  grains  of 
calomel,  followed  in  about  three  hours  by  a  draught  of 
senna  and  sulphate  of  magnesia,  this  generally  induces 
bilious  but  not  very  watery  motions.  To  promote  the 
action  of  the  skin,  the  vapour  bath  should  not  be  employed 
at  once,  but  the  patient  wrapped  in  blankets,  and  a  few  hot 
water-bottles  placed  round  him,  as  soon  as  he  begins  to 
feel  the  effect  of  the  warmth,  the  blankets  should  be  sup- 
ported by  a  cradle,  and  the  vapour  introduced  from  a 
steam  kettle,  the  amount  of  sweating  should  be  carefully 
regulated,  and  never  be  allowed  to  become  profuse.  The 
patient  should  be  encouraged  to  drink  from  time  to 
time  some  simple  diluent,  in  order  to  restore  the  amount 
of  water  withdrawn.  If,  however,  the  uremic  symptoms 
have  come  on  suddenly  without  warning,  and  the  patient 
after  a  severe  convulsion,  passes  into  a  state  of  profound 
coma,  we  must  employ  other  measures.  If  the  patient 
is  strong  and' vigorous,  and  the  nephritis  is  due  to  expo- 
sure to  cold,  or  is  attendant  on  pregnancy,  then  venesec- 
tion affords  the  speediest  and  most  sure  measure  of  relief. 
If,  however,  the  ursemic  symptoms  occur  in  patients 
weakened  by  previous  disease,  as  often  happens  after 
scarlet  fever,  then  the  injection  of  pilocarpine,  x5  to  ^ 
grain,  repeated  if  necessary  at  intervals  of  six  hours, 
under  the  skin,  must  be  chiefly  relied  on,  though  in  these 


TREATMENT    OF   NEPHRITIS.  255 

cases,   the   moderate  withdrawal  of  blood  by  means  of 
leeches  is  also  advantageous. 

It  is  astonishing  what  relief  is  obtained  by  venesec- 
tion in  puerperal  eclampsia.  In  a  case,  whose  urine 
I  examined  for  Dr.  John  Williams  last  year,  venesec- 
tion was  always  followed  by  cessation  of  the  convulsive 
seizures,  whilst  the  change  in  the  character  of  the  urine 
was  most  marked,  the  urine  of  the  twelve  hours  following 
venesection  containing  only  one  half  the  quantity  of  albu- 
min of  the  preceding  twelve  hours,  whilst  the  amount  of 
urine  and  urea  excreted,  was  increased. 

For  the  immediate  relief  of  the  epileptiform  attacks,  in- 
halation of  chloroform  must  be  employed. 

Dropsy,  when  excessive,  should  be  relieved  by  means  of 
gentle  purgatives  and  the  vapour  bath,  in  the  manner 
already  described.     For  the  small  dose  of  calomel,  however, 
a  pill  which  contains  one  grain  of  blue  pill,  and  half  a  grain 
each  of  powdered  digitahs  leaves  and  extract  of  squill,  should 
be  substituted,  and  a  mixture  containing  twenty  grains 
each  of  sulphate  of  potash  and  acetate  of  potash,  in  ^  iss 
of  infusion  of  jaborandi,  given  every  four  hours.    The  sul- 
phate keeps  the  bowels  sufficiently  loose,  whilst  the  acetate 
acts  as  a  gentle  diuretic  ;  both  jaborandi  and  pilocarpine 
are  useful  in  acute  renal  dropsy,  though  their  administra- 
tion in  chronic  renal  dropsy  is  often  followed  by  headache, 
and    occasionally    by    more    alarming    head   symptoms. 
Dropsical  effusion  into  the  serous  cavities  of  the  pleurae 
and  peritoneum  is  not  of  such  frequent  occurrence  as  in 
chronic  nephritis,  but   when  it  occurs  it  is  usually  ur- 
gent;   the  general  treatment  of  such  an  event  must  be 
on  the  same  lines  as  that  directed  for  the  relief  of  the 
subcutaneous   oedema.     Unlike   what   occurs    in   chronic 
nephritis,  it  is  rare  for  puncture  to  be  required  for  the 
removal  of  either  subcutaneous   or  serous    effusions  in 


256  DISEASES    OF    THE    KIDNEY. 

acute  renal  dropsy ;  if,  however,  the  swelling  comes  on 
very  rapidly,  and  the  distension  is  very  great,  it  should  be 
resorted  to  without  delay. 

The  gastric  disturbance  at  the  onset  is  often  so  severe 
as  to  require  attention,  and  means  have  to  be  adopted  to 
check  the  excessive  vomiting.  This  in  acute  nephritis,  as 
already  stated,  is  generally  reflex  and  not  ursemic.  Ke- 
flex vomiting,  as  a  rule,  is  best  treated  by  the  adminis- 
tration of  small  quantities  of  morphia  and  opium  ;  in  this 
case,  however,  opiates  cannot  be  administered  with  safety, 
and  we  have  to  fall  back  on  less  reliable  remedies.  Drop 
doses  of  hydrocyanic  acid  in  a  tea-spoonful  of  water  every 
two  hours,  linseed  and  mustard  poultices  to  the  epigas- 
trium, and  iced  Apollinaris  water,  will  be  found  perhaps  to 
give  most  relief.  In  acute  nephritis,  following  exposure 
to  cold,  which  is  attended  with  considerable  swelling  of  the 
kidney,  and  distension  of  the  capsule,  the  pain  is  often 
very  severe ;  when  this  is  the  case,  relief  is  best  obtained 
by  enveloping  the  loins  in  a  linseed  poultice,  and  covering 
the  abdomen  with  flannels  wrung  out  in  hot  water,  and 
sprinkled  with  tincture  or  liniment  of  belladonna.  If  the 
pain  is  very  severe,  leeches  must  be  applied  to  the  flank. 

So  long  as  the  urine  remains  scanty  and  dark  coloured, 
the  disease  must  be  considered  acute ;  when,  however,  the 
urine  becomes  daily  more  abundant,  of  lighter  colour,  and 
lower  specific  gravity,  even  though  it  still  contain  a  con- 
siderable amount  of  albumin,  then  the  period  of  decline  is 
reached,  and  our  treatment  must  be  modified  accordingly. 
It  is  at  this  stage  that  iron  is  of  the  greatest  benefit  in 
preventing  any  further  progress  of  the  anaemia  that  has 
already  occurred  The  choice  of  the  ferruginous  prepara- 
tion must  depend  on  the  state  of  the  digestive  organs,  and 
at  first  only  the  mildest  can  be  borne.  Griffith's  mixture, 
the  Mist.  Ferri  Co.  of  the  Pharmacopoeia,  or  the  Mist. 


TEEAT3IENT    OF    NEPHRITIS.  257 

Feri'i  c.  Saliua  of  the  London  Hospital,  whicli  latter  con- 
tains 10  grains  of  animonio- citrate  of  iron,  and  15  grains 
of  citrate  of  potash,  usually  agree  best  at  first.  As  soon 
however,  as  the  patient  can  take  the  stronger  preparations, 
such  as  the  perchloride,  the  better. 

It  will  be  observed,  that  I  have  as  yet  said  nothing 
with  regard  to  special  remedies  advised  in  acute  ne- 
phritis, such  as  fuschine,  tannin,  tannate  of  soda,  etc. ; 
these  drugs,  which  are  much  employed  in  Germany, 
are  however  little  resorted  to  in  this  country.  They 
no  doubt,  when  administered  in  sufScient  doses,  dimin- 
ish the  amount  of  albumin  in  the  urine,  but  that  is 
not  a  matter  of  immediate  importance  in  acute  nephritis, 
our  great  object  being  to  subdue  the  inflammation,  and 
provide  for  the  elimination  of  the  urinary  constitaents. 
If  emx^loyed  at  all,  they  may  be  of  service  in  sub-acute 
nephritis,  or  when  the  acute  inflammation  passes  into  the 
chronic  stage,  and  when  it  may  be  necessary  to  check  the 
drain  on  the  system,  caused  by  the  long-continued  with- 
drawal of  albumin,  but  even  then  I  think  perchloride  of 
iron  answers  the  purpose  better.  The  only  special  remedy 
it  will  be  found  necessary  to  employ,  is  in  the  case 
of  acute  malarial  nephritis:  "Nothing,"  says  Professor 
Atkinson  (oj).  cit.),  "  can  be  expected  to  control  the  hyper- 
emia that  does  not  bring  the  impaludism  under  subjection," 
for  this  purpose,  quinine  in  large  doses  must  be  given,  tiU 
all  symptoms  of  malarial  cachexia  have  disax^peared. 

As  already  stated,  the  employment  of  powerful  hydra- 
gogue  purgatives  or  active  diaphoresis,  should  be  avoided 
during  the  progress  of  acute  nephritis,  a  similar  caution 
must  also  be  directed  against  the  use  of  stimulating  or 
irritating  diuretics  ;  nor  should  iron  in  any  form  be  given 
till  the  acute  stage  subsides,  whilst  no  practitioner  would 
think  of  administering  opium  at  any  stage  of  nephritis. 

s 


258  DISEASES    OF    THE    KIDNEY. 

Slioiild  it  be  necessary  to  relieve  pain,  cliloral  hydrate 
can  be  safely  administered,  indeed,  some  prefer  it  to 
chloroform  for  the  control  of  nrasmic  convulsions. 

When  the  stage  of  convalescence  is  reached,  the  patient 
must  not  be  lost  sight  of  too  soon,  for  long  after  he  appears 
to  have  regained  his  usual  health,  traces  of  albumin  will 
be  found  in  the  urine,  especially  after  exercise,  food,  or 
exposure  to  cold.  Besides  a  relapse  has  to  be  guarded 
against,  and  as  this  takes  generally  the  insidious  form  of 
sub- acute  nephritis,  considerable  mischief  may  occur  be- 
fore it  is  detected.  The  urine,  therefore,  should  be  fre- 
quently examined,  and  if  the  albumin,  however  small  a 
trace,  is  persistent,  the  patient  must  be  kept  under  close 
medical  supervision.  It  is  at  this  stage  that  the  adop- 
tion of  an  absolute  milk  diet  for  some  weeks,  or  even 
months,  may  be  employed  with  the  greatest  success,  many 
patients  losing  their  albuminuria  almost  as  soon  as  placed 
upon  it.  The  directions  for  carrying  out  the  milk  diet, 
will  be  entered  upon  more  fully  when  we  speak  of  it  in 
reference  to  the  treatment  of  chronic  tubal  nephritis. 
The  patient  should  persist  in  the  use  of  iron  tonics,  till  the 
ansemia  has  quite  disappeared.  Cold  should  be  guarded 
against  by  wearing  flannel,  and  by  avoiding  exposure. 
Convalescence  is  greatly  aided  by  a  temporary  residence  in 
a  warm  but  bracing  atmosphere,  with  dry  sub- soil.  In 
England  the  best  places  are  Folkestone,  originally  recom- 
mended by  Dr.  Bright  for  this  purpose,  Clevedon,  Clifton, 
and  Weston-super-Mare,  The  latter  places  enjoy  an 
equable  bracing  air,  well  sheltered,  and  a  dry  sub- soil 
of  limestone  rock. 

Chronic  tubal  nephritis,  which  may  be  a  continuation  of 
an  acute  nephritis,  or  may  arise  insidiously  in  a  sub- 
acute form,  requires  but  little  modification  from  the  above 
described  method  of  treatment.      During  the  development 


TEEATMENT    OF    NEPHRITIS.  259 

of  the  diseaBe,  or  in  its  exacerbatioBS,  when  the  nrine  is 
scanty  and  highly  albuminous,  the  patient  uinst  be  kept  in 
bed.  As,  however,  nrsemic  symptoms  are  not  developed  in 
this  disease,  till  it  has  progressed  and  entered  upon  the 
stage  of  contraction,  there  is  not  the  same  necessity  for  an 
absolute  non-nitrogenous  diet,  as  in  the  preceding  in- 
stance, and  though  large  quantities  of  milk  are  not  advis- 
able, so  long  as  the  urine  is  highly  albuminous,  it  need  not 
be  entirely  cut  off,  but  may  be  used  in  moderation.  For 
a  similar  reason  in  the  treatment  of  the  dropsy,  we  need 
not  fear  the  effects  of  withdrawing  water  from  the  blood 
to  too  great  an  extent,  by  means  of  jDurgatives  and  sweat- 
ing, as  in  acute  nephritis.  And  this  is  fortunate,  since 
the  dropsy  of  chronic  tubal  nephritis  is  generally  more 
difficult  to  get  rid  of,  than  in  the  acute  form.  Ordin- 
arily, however,  it  is  sufficient  to  give  nightly,  till  the 
oedema  subsides,  the  pill  already  mentioned  (p.  255), 
and  during  the  day  a  mixture  containing  a  saline 
aperient,  such  as  sulphate  of  potash.  Digitalis,  too, 
is  most  efficacious  in  this  form  of  dropsy,  since  by  in- 
creasing the  pressure  in  the  renal  vessels,  it  acts  as  a 
direct  diuretic.  Broom-tops,  too,  have  long  had  a  reputa- 
tion as  a  diuretic,  and  should  form  an  ingredient  of  our 
prescription,  of  which  the  following  is  a  convenient  form. 
Potassae  acetatis,  gr,  xv. ;  potassse  sulphatis,  gr.  xxx. ; 
tinct.  digitalis,  tix  viii. ;  spiriti  juniperi,  iri  xv. ;  decocti 
scoparii,  ad  f  iss.  Three  or  four  times  daily.  The 
action  of  purgatives  and  diuretics  should  be  seconded  by 
promoting  the  action  of  the  skin.  Most  authorities  are 
agreed,  contrary  to  what  occurs  in  health,  that  sweating 
is  followed  by  an  increased  flow  of  urine,  the  hypersemia 
of  the  skin  relieving  that  of  the  kidneys.  For  this  purpose 
the  vapour  bath  administered  as  directed  for  the  treatment 
of  acute  renal  dropsy,  is  the  most  convenient.      After 

s2 


260  DISEASES    OP    THE    KIDNEY. 

sweating  has  been  established,  the  action  may  be  gently 
maintauied  by  placing  hot  water  bottles  in  the  bed,  or 
warm  bran  bags  next  to  the  patient.  Pilocarpine  and 
jaborandi,  which  prove  so  serviceable  in  acute  nephritis, 
are  not  equally  useful  in  chronic  renal  dropsy,  since  owing 
to  the  difficulty  with  which  the  skin  can  be  got  to  act,  their 
administration  is  often  followed  by  headache,  and  even  by 
alarming  cerebral  symptoms,  and  pulmonary  complications 
have  been  known  to  follow  their  use.  They  maybe  employed, 
however,  after  the  skin  has  been  got  to  act  by  means  of 
the  vapour  bath,  when  a  few  doses  of  infusion  of  jaborandi 
may  be  given  to  continue  the  diaphoresis.  If,  however,  in 
sj)ite  of  this  treatment  the  dropsy  continues  to  increase,  or 
does  not  yield,  we  may  try  stronger  cathartics,  such  as 
comi^ound  jalap  powder  or  elaterium,  but  we  must  always 
remember  the  risk  we  run  in  exciting  dangerous  diarrhoea, 
which  is  especially  likely  to  occur  in  patients  who  have 
already  suffered  from  repeated  attacks  of  dropsy.  Indeed, 
purgatives  in  any  form  must  be  carefully  administered  if 
there  is  a  tendency  to  spontaneous  diarrhoea.  Stimula- 
ting diuretics,  such  as  turpentine,  copaiba,  or  the  like, 
are  useful,  especially  when  the  dropsy  is  recurrent. 
Copaiba  may  be  given,  as  Dr.  Wilks  recommends,  in  the 
form  of  a  bolus,  or  enclosed  in  capsules,  by  this  means  its 
nauseous  taste  is  disguised. 

Chronic  renal  dropsy  requires  to  be  relieved  by  punc- 
ture, more  frequently  than  that  resulting  from  acute  nephri- 
tis. As  it  is  advisable  to  make  as  few  wounds  as  possi- 
ble, Southey's  iine  canula  especially  made  for  this  purpose 
should  be  employed,  by  which  means  one  puncture,  or  at 
the  most  one  for  each  leg,  is  required.  The  canula  should 
be  allowed  to  remain  in  for  about  five  or  six  hours,  during 
which  time  a  considerable  amount  of  fluid  will  be  with- 
drawn.     Not  only  does  this  drainage  relieve  the  distended 


TREATMENT    OF    NEPHRITIS,  2G1 

tissues,  but  promotes  the  diuresis,  so  tbat  althoufjh  only  a 
portion  of  the  fluid  is  withdrawn  from  the  tissues  by  the 
puncture,  the  remainder  usually  disappears  in  the  course 
of  a  day  or  so. 

Owing  to  the  readiness  with  which  inflammation  occurs 
in  the  cellular  tissue,  in  these  cases,  it  is  not  advis- 
able to  leave  the  drainage  tubes  longer  than  the  time 
mentioned,  even  then  it  will  sometimes  unfortunately 
occur.  The  risk,  however,  may  be  diminished  by  swabbing 
the  skin,  surrounding  the  puncture,  previously  with  some 
stimulating  application,  such  as  tincture  of  benzoin,  and 
when  the  canula  is  withdrawn,  the  wound  should  be  lightly 
covered  with  carbolized  tow  or  cotton  wool.  The  pro- 
found ansemia  which  occurs  in  chronic  tubal  nephritis, 
calls  for  the  early  administration  of  iron.  At  first  whilst 
the  urine  is  scanty,  the  citrates  and  tartrates  are  the  best 
preparations,  which  can  be  administered  with  the  saline 
salts  of  the  same  acids.  Later,  with  a  freer  flow  of  urine, 
the  perchloride  may  be  more  advantageously  employed, 
this  may  be  given  in  a  mixture  containing  liquor  ammonise 
acetatis,  which  though  not  a  chemical,  is  an  elegant  and 
useful  combination.  Should  the  amount  of  albumin  passed 
daily,  continue  excessive,  so  as  to  constitute  a  severe 
drain  on  the  system,  we  may  try  the  effect  of  doses  of 
fuschine  or  tannate  of  soda.  Fuschine  in  one  to  three  grain 
doses  daily,  has  been  favourably  reported  on  by  Bergeron, 
Dochman  and  Bamberger  for  this  purpose,  and  tannate  of 
soda,  originally  suggested  by  Lewin,  has  also  been  found 
serviceable.  However  that  may  be,  the  steady  administra- 
tion of  iron  must  not  be  superseded  by  these  drugs. 

With  the  disappearance  of  the  dropsy,  and  with  a  more 
abundant  discharge  of  urine,  we  may  hope  that  the  renal 
hyperemia  is  subsiding,  and  that  complete  recovery  is 
possible.     Even  after  the  process  has  continued  a  con- 


262  DISEASES    OF    THE    KIDNEY. 

siderable  time,  and  altliotigli  relapses  have  been  frequent, 
we  need  not  despair,  if  the  patient  will  aid  us  by  strictly- 
obeying  our  hygienic  and  dietetic  instructions.  He  must 
be  warmly  clad,  flannel  next  the  skin,  and  carefully  shelter 
himself  against  all  exposure  to  cold  and  damp,  that  is 
remain  in- doors  in  wet  weather,  or  during  the  prevalence 
of  cold,  especially  Easterly,  winds.  He  should  not  be  per- 
mitted to  fatigue  himself,  but  should  avoid  long  walks, 
long  railway  journeys,  fatiguing  business,  or  anything 
likely  to  depress  his  bodily  or  mental  powers.  If  possi- 
ble, he  should  fix  his  residence  for  some  time  in  a  warm 
climate  with  a  dry  sub-soil.  Voyages  to  the  Tropics  have 
been  recommended  for  such  cases,  but  as  it  is  difficult  ta 
regulate  the  diet  on  board  ship  satisfactorily,  I  think 
he  is  likely  to  find  there  is  more  comfort  and  safety 
in  a  well  regulated,  furnished  residence  at  a  health 
resort,  of  which  in  England,  Folkestone,  Bournemouth, 
Clevedon,  Clifton,  Weston-super-Mare,  Tenby,  stand  in 
the  first  rank  for  this  purpose.  The  diet  must  be  light, 
at  first  chiefly  farinaceous,  but  if  the  albuminuria  remains 
persistent,  even  though  the  general  health  has  improved, 
an  absolute  milk  diet  should  be  gradually  enforced.  This 
diet  though  of  little  use,  indeed  I  have  in  one  case  found  ic 
positively  do  harm  during  the  early  period  of  the  disease, 
is  most  advantageously  employed  during  the  subsidence 
of  the  disease.  Dr.  George  Johnson  {Brit.  Med.  Journal, 
Aug.  16,  1884)  relates  the  case  of  a  gentleman,  who  after 
having  suffered  from  the  disease  a  considerable  number  of 
years,  adopted  a  milk  diet  for  a  considerable  period,  taking 
half  a  pint  every  two  hours,  and  ultimately  recovered. 
Dr.  Embleton  of  Bournemouth  has  sent  me  the  notes  of  a 
case  we  saw  together  last  year,  in  which  after  a  continu- 
ance of  a  milk  diet  for  nine  months,  after  the  disease  had 
existed  for  two  years,  the  albumin  almost  entirely  dis- 


TBEATMENT    OF    NEPHRITIS.  263 

appeared.  Both  Dr.  Johnson  and  Dr.  Embleton  have 
noted  the  remarkable  fact,  that  if  any  mgredient,  how- 
ever innocent,  such  as  arrowroot,  or  sugar,  was  added  to 
the  milk,  there  was  an  increase  of  the  albuminuria. 
Dr.  Embleton,  however,  found  that  some  of  the  milk  may 
be  taken  as  curds  and  whey.  It  is  usual  to  begin  with 
skim  milk,  not  that  there  is  any  special  virtue  in  it,  but 
that  unskimmed  milk  taken  in  large  quantities,  is  apt 
to  make  the  patients  bilious,  till  they  get  accustomed  to 
the  diet.  After  a  time  they  may  gradually  replace 
the  skimmed  with  unskimmed  milk.  Dr.  Embleton  has 
noticed  that  palpitation  of  the  heart  sometimes  occurs 
during  the  continuance  of  this  diet,  which  he  thinks  may  be 
caused  by  the  action  of  the  potassium  salts,  which  are  par- 
ticularly abundant  in  milk,  and  he  advises  the  administra- 
tion of  some  mineral  water,  rich  in  other  bases,  to  correct 
this  excess.  The  milk  diet  has  no  injurious  effect  on  the 
general  health,  and  can  be  continued  for  months,  and  even 
years  if  necessary,  the  patient  gaining  in  flesh  the  while. 
Although  the  absolute  milk  treatment  should  never  be 
omitted  when  the  albuminuria  is  persistent,  still  there  are 
many  cases  which  get  well  without  the  necessity  for  em- 
ploying such  a  rigorous  measure,  whilst  again  there  are 
other  patients  who  have  not  the  fortitude  to  persevere  with 
it.  In  these  cases,  good  results  may  be  obtained  by  keep- 
ing the  patient  on  a  light  and  simple  dietary,  which  should 
be  almost  "  vegetarian."  The  following  table  will  indicate 
the  kind  of  dishes  the  invalid  may  order. 

Breakfast. — Cocoa  and  milk,  or  bread  and  milk;  toast; 
rashers  of  bacon  toasted  (fat  only)  ;  boiled  fish  with  rice ; 
sardines;  boiled  rice  with  a  little  sugar,  jam,  or  stewed 
fruit ;  boiled  tomatoes ;  fresh  fruit  such  as  grapes, 
strawberries,  cherries,  and  oranges,  or  a  soft  ripe  j)ear. 
Lunch  or  Supper. — A  basin  of  arrowroot,  flavoured  with 


264  DISEASES  OF  THE  KIDNEY. 

a  table- spoonful  of  Marsala  or  sweet  sherry ;  bread  and 
butter  pudding ;  also  varieties  of  tapioca,  sago,  rice,  and 
custard  puddings.  Dinnek. — Vegetable  soups,  like  croute 
au  pot ;  or  milk  soups,  like  St.  Germaine ;  all  kinds  of 
boiled  fisli,  witli  good  melted  butter,  but  no  added  sauce  ; 
boiled  calf's  head,  or  knuckle  of  veal  with  bacon ;  boiled 
neck  of  mutton  ;  sweetbreads  ;  stewed  calf's  or  pig's  feet ; 
well  kept  and  tender  game,  such  as  grouse,  pheasant, 
XDartridge,  snipe,  plover,  or  woodcock,  may  be  permitted 
occasionally  as  a  change.  Vegetables  of  all  kinds  may  be 
used  except  those  of  the  leguminous  order.  It  makes  a 
pleasant  variety  in  a  limited  dietary  to  have  one  good 
vegetable  served  by  itself,  French  fashion,  at  dinner.  No 
cheese  in  any  form  is  to  be  permitted,  instead  water-cress 
with  slice  of  bread  and  butter,  or  a  little  plain  dressed 
ealad,  or  laver.  For  the  sweets,  any  simple  kind  of  boiled 
or  baked  farinaceous  pudding  with  stewed  fruits,  care 
"being  taken  that  the  eggs  used  in  their  preparation  should 
be  limited,  and  only  the  yolks  employed.  Dessert. — 
Orai^es,  oranges,  strawberries,  cherries,  pears  if  tender 
and  of  good  quality.  Apples,  nuts,  pineapples,  etc.,  not 
advisable. 

The  patient  should  abstain  completely  from  alcohol,  tea 
a,nd  coffee.  Should,  however,  the  digestion  be  very  feeble,  a 
table -spoonful  of  Marsala  in  a  wine-glass  of  water  may  be 
taken  at  dinner  to  stimulate  the  secretion  of  the  gastric  juice, 
or  in  a  basin  of  arrowroot  before  going  to  bed.  Eggs  and 
cheese  should  be  avoided,  since  it  has  been  shown  that  egg 
albumin  and  casein,  even  in  some  healthy  persons,  pass 
more  readily  through  the  renal  vessels,  than  does  serum 
albumin.  The  meal  hours  should  be  regular,  and  the 
patient  should  be  encouraged  to  rest  for  an  hour  or  so 
after  taking  food.  The  amount  of  food  taken  should  be 
limited  to  the  actual  requirements  of  the  body,  and  the 


TREATBIENT    OF    NEPHEITIS.  2G5 

patient  sliould  always  stop  far  short  of  repletion,  indeed 
he  should  leave  the  table  with  his  appetite  appeased,  but 
not  satisfied.  The  importance  of  regulating  the  quantity 
of  the  food,  and  not  over-loading  the  digestive  organs,  is  in 
my  estimation,  greater  even  than  rigidly  supervising  the 
quality. 

If  the  patient  remains  free  from  relapses,  and  will  con- 
sent to  follow  the  plan  above  indicated,  adopting  an  abso- 
lute milk  diet,  if  the  modified  prove  insufficient,  we  may 
have  good  hopes  for  his  recovery,  even  if  the  albuminuria 
has  lasted  some  years.  Dr.  Johnson's  patient  recovered 
under  the  absolute  milk  treatment,  after  the  disease  had,  I 
believe,  existed  for  more  than  seven  years.  In  a  case 
which  came  recently  under  my  care  after  the  disease  had 
existed  for  two  years  before  my  seeing  him,  five  months 
adherence  to  the  modified  system  of  diet,  as  sketched  above, 
cured  him.  If,  however,  relapses  are  frequent,  and  the 
patient  will  not,  or  cannot,  take  sufficient  care  of  himself, 
the  disease,  unless  cut  short  by  some  intercurrent  affec- 
tion, will  progress  to  the  next  stage  that  of  atrophy  and 
contraction.  The  treatment  of  which  being  practically 
the  same  as  for  the  granular  condition  of  the  kidney, 
arising  from  chronic  interstitial  nephritis,  will  be  most 
conveniently  considered  together  in  the  next  paragraph. 

Chronic  interstitial  7iepJiritis. — In  granular  kidney  re- 
sulting from  chronic  interstitial  nephritis,  we  meet  with 
two  well  marked  clinical  conditions.  In  the  first,  cardio- 
vascular changes,  pulse  of  high  tension,  and  hypertrophy 
of  the  left  ventricle,  precede,  or  simultaneously  accompany 
the  renal  affection.  In  the  other  condition,  the  renal  dis- 
order is  observed  some  time  before  the  cardio-vascular 
changes  are  noticed.  Of  the  two  conditions  the  first  is 
markedly  characteristic  of  the  small  red  granular  kidney, 
and  confirms  the  view  expressed  by    Sir  "W.    Gull   and 


266  DISEASES    OF    THE    KIDNEY. 

Dr.  Sutton,  that  this  form  of  renal  disorder  is  the  outcome 
of  a  general  primary  constitutional  condition  ;  the  second 
always  indicates  some  preceding  disorder  of  the  urinary 
passages,  such  as  long- continued  pyelitis,  cystitis,  or 
chronic  tubal  nephritis.  The  chief  therapeutic  indications 
in  both  conditions  are,  however,  the  same,  viz.,  to  diminish 
as  much  as  possible  the  vascular  tension,  and  to  restrain 
the  hyperplasia  of  the  renal  connective  tissue.  The  first 
indication  is  best  fulfilled  by  insistance  on  an  abstemious 
diet  and  rest.  The  ordinary  diet  should  be  the  same  as  that 
recommended  for  chronic  tubal  nephritis,  but  should  there 
be  symptoms  of  extreme  elevation  of  the  blood  pressure  in 
the  aortic  system,  the  patient  ought  to  be  kept  for  a  time 
on  an  absolute  milk  diet.  Best  must  be  resolutely  in- 
sisted on.  Nothing  aggravates  the  condition  so  much  as 
undue  exertion.  This  is  one  reason,  why  this  class  of 
patient  generally  improves  so  greatly  when  they  come  un- 
der the  care  of  the  physician,  because  then  for  a  time  they 
may  be  persuaded  to  give  iip  their  usual  avocations.  In  a 
chronic  disease  like  this,  it  is  impossible  to  enforce  abso- 
lute continuous  rest,  hfe  would  not  be  worth  having  on 
such  terms,  but  life  may  not  only  be  prolonged,  but  indeed 
fairly  enjoyable  if  certain  conditions  are  complied  with.  For 
instance,  when  the  patient  first  comes  under  observation, 
or  during  an  exacerbation  of  the  disease,  if  he  will  consent 
to  remain  in  bed,  and  keep  on  low  diet  for  a  few  days,  he 
may  be  permitted,  if  free  from  palpitation,  giddiness,  or 
oppression  of  breathing,  at  the  end  of  that  time  to  move 
about  his  room  a  little,  and  afterwards  if  there  be  no  recur- 
rence of  the  urgent  symptoms  to  go  out,  and  by  degrees 
resume  his  general  avocations,  though  he  will  do  wisely  to 
limit  these  as  much  as  possible.  If  wealthy  he  should 
retire  from  business,  and  all  exciting  pursuits,  if  poor  he 
should  be  content  to  earn   less   wages,  by  undertaking 


TEEATJIENT    OF   NEPHRITIS. 


267 


lighter  engagements,  or  doing  less  work.  He  should  re- 
side near  his  place  of  business  to  avoid  the  fatigue  of  the 
morning  and  evening  journej^  by  omnibus,  cab  or  rail,  to 
and  from  the  city.  If  possible  the  bedroom  should  be  on 
the  ground  floor,  at  all  events  the  necessity  for  mounting 
flights  of  steps,  or  ascending  even  moderate  heights  is  to 
be  avoided,  and  above  all  things  the  patient  should  be 
■warned  against  hm-ry  of  any  hind.  By  enforcing  such 
regulations  we  shield  the  patient  from  sudden  and  extreme 
elevations  of  the  aortic  blood  pressure,  which  not  only 
tend  to  aggravate  the  renal  disorder,  but  are  also  highly 
dangerous  owing  to  the  degenerated  condition  of  the  arteries 
that  generally  exists.  A  little  gentle  exercise  at  a  slow 
pace  on  the  level  should  not  be  forbidden,  if  the  patient 
has  no  business  engagements  to  fatigue  him,  otherwise 
those  will  be  sufiicient. 

With  regard  to  therapeutic  treatment,  nitro-glycerine 
has  been  recommended  for  the  relief  of  the  arterial  ten- 
sion. It  is  undoubtedly  serviceable  in  cases  where  there 
is  an  exacerbation  of  the  disease,  especially  when  attended 
with  dyspnoea  (renal  asthma) .  Iodide  of  potassium  also  has 
a  powerful  influence  in  diminishing  cardiac  action,  and  as  it 
also  tends  to  restrain  the  hyperplasia  of  the  renal  organs, 
it  should  form  the  basis  of  our  treatment.  I  agree  with 
Bartels,  that  in  moderate  doses  (5-10  grains)  thrice  daily, 
it  can  be  administered  for  months  without  any  prejudicial 
effect.  In  order  to  act  on  the  connective  tissue,  minute 
doses  of  bichloride  of  mercury  (-gL  grain)  may  be  given 
with  the  iodide.  As  however,  patients  v/ith  granular  kid- 
neys are  extremely  susceptible  to  the  action  of  mercury,  it 
must  be  carefuUy  watched,  and  its  administration  sys- 
tematically interrupted.  Bartholovr  {New  York  Medical 
Record,  June  28th,  1884,)  has  recently  recommended  in 
place  of  mercury,  the  double  chloride  of  gold  and  sodium 


268  DISEASES    OF    THE    KIDNEY. 

{^■Q  grain)  as  having  tlie  same  effect.  I  have  had  no 
experience  of  the  drug  as  yet,  hut  should  it  possess  the 
advantage  of  the  hichloride  without  its  drawback,  we 
ought  to  he  deeply  indebted  for  the  suggestion.  Great 
attention  should  be  paid  to  the  action  of  the  bowels,  since 
arterial  tension  always  rises  when  they  are  constipated ; 
whilst  owing  to  the  degenerated  condition  of  arteries, 
cerebral  haemorrhage  may  be  induced  by  the.  straining 
caused  by  a  hard  motion.  For  this  purpose  a  dose  of 
some  aperient  mineral  water,  Pullna,  Hunyadi  Janos,  etc., 
taken  before  breakfast  is  the  best.  For  the  relief  of  com- 
plications special  treatment  is  required.  Of  these,  the 
chronic  uraemic  symptoms  are  the  most  troublesome.  The 
muscular  twitchings  and  troublesome  itching  of  the  skin 
may  be  controlled  by  chloral,  and  by  paying  particular  at- 
tention to  the  state  of  the  skin  and  bowels.  As  neither  hot 
vapour  or  air  baths  are  advisable  in  this  form  of  renal  dis- 
ease, owing  to  the  preliminary  state  of  arterial  tension 
they  induce,  prior  to  sweating,'|some  other  means  of  acting 
on  the  skin  must  be  devised,  and  the  best  are  either  tepid 
douches  of  sea- water  (sea-salt)  or  the  cold  pack.  I  prefer 
the  former,  and  patients  have  expressed  themselves  most 
grateful  for  the  relief  afforded  by  it.  If  possible  the  tem- 
perature should  be  regulated,  beginning  at  about  90°  F., 
and  falling  to  about  75°  F.  The  saline  solution  powerfully 
stimulates  the  skin,  whilst  the  douche  acts,  I  fancy,  as  a 
kind  of  gentle  massage.  Ur^emic  vomiting  may  be 
often  checked  by  the  application  of  a  cold  compress  across 
the  abdomen,  or  a  small  mustard  plaster  to  the  pit  of  the 
stomach  over-night.  If  urgent  an  effervescing  draught 
containing  two  minims  of  hydrocyanic  acid  will  often  give 
relief.  Ursemic  headache  is  often  stopped  by  the  adminis- 
tration of  twenty  drops  of  dilute  nitric  acid  in  water.' 
Uraemic  asthma  is  best  treated  with  nitro- glycerine,  at  the 


TKEATMENT    OF    NEPHRITIS.  269 

onset  of  the  paroxysms.  The  onset  of  these,  as  of  all 
ursemic  symptoms,  points  to  the  necessity  of  free  action  of 
the  bowels,  and  if  not  contra-indicated,  a  grain  of  calomel 
followed  by  a  saline  aperient  is  the  best  agent,  since  it 
produces  copious  bilious  stools,  and  thus  affords  consider- 
able relief  to  the  system.  If  calomel  cannot  be  borne,  then 
a  sufficient  dose  of  sulphate  of  magnesia  must  be  given. 
Albuminuric  retinitis  must  be  treated  on  general  principles. 
I  have  found  that  the  administration  of  small  quantities  of 
mercury  are  most  useful  in  restraining  its  course,  and 
even  of  repairing  the  damage  already  done.  An  out- 
patient at  the  London  Hospital,  who  had  previously  been 
under  treatment  at  Moorfields  for  six  months,  taking 
during  that  time  large  doses  of  iodide  of  potassium,  re- 
covered, in  three  weeks,  under  the  administration  of  one 
grain  of  grey  powder  twice  a  day,  so  far  as  to  be  able  to 
walk  to  the  hospital  unaided,  whereas  when  he  first  came 
he  had  to  be  led  by  an  attendant. 

With  regard  to  the  formidable  haemorrhages  that  occur 
in  the  course  of  this  disease,  our  treatment  must  be  regu- 
lated by  the  imminent  danger  they  present.  If  the 
haemorrhage  occur  from  a  cerebral  vessel,  and  the  pulse  is 
tense,  and  the  heart's  action  energetic,  we  ought  not  to 
hesitate,  but  bleed  promptly.  If  on  the  other  hand,  the 
rupture  occurs  in  a  later  stage  of  the  disease,  v/hen  the 
heart's  action  has  become  feeble,  and  the  tension  in  the 
aortic  system  has  fallen,  and  the  lesion  is  caused  not  by 
the  distension  of  the  vessel,  but  by  its  degenerated 
condition,  then  no  good  will  be  obtained  by  venesection. 
In  this  case  the  head  should  be  kept  well  raised,  ice  blad- 
ders applied,  and  a  sharply  acting  aperient  given  by  the 
mouth.  In  "  pulmonary  apoplexy  "  the  rule  should  be  to 
bleed  on  the  first  onset  of  the  symptoms  if  the  pulse  is 
incompressible.     In  epistaxis  the  danger  is  not  so  immiu- 


270  DISEASES    OF    THE    KIDNEY. 

ent.  We  may  begin  with  milder  measures,  sucli  as  keep- 
ing the  patient  in  an  horizontal  position,  plugging  the  nos- 
trils, application  of  ice  bags  over  the  region  of  the  heart, 
the  administration  of  gallic  acid,  and  if  these  means  are 
not  sufiicient,  then  the  application  of  a  few  leeches  ;  these 
latter  are  most  advantageously  applied  round  the  anus. 
In  cases  of  severe  epistaxis  which  resist  every  measure, 
Dr.  Dieulafoy  {Gaz.  Hebdom.,  Jan.  18th,  1884)  recom- 
mends transfusion  of  blood,  believing  that  the  injection  of 
normal  blood  acts  as  an  hffimastatic  by  restoring  the  com- 
position of  the  imj)aired  blood,  and  he  relates  a  case  in 
which  repeated  attacks  of  hffimorrhage  were  alone  arrested 
by  the  injection  of  120  grms.  of  healthy  blood.  Haemor- 
rhages from  other  mucous  surfaces  are  to  be  treated 
in  the  same  manner  as  epistaxis.  When  hsemorrhage 
has  once  occurred,  it  is  an  additional  reason  for  enforcing 
rest  and  a  spare  dietary.  In  the  early  stage  and  during 
the  progress  of  the  disease,  both  digitalis  and  iron  are 
contra-indicated,  owing  to  their  increasing  the  tension  an 
the  aortic  system.  In  the  later  stage,  however,  when  the 
heart  begins  to  flag,  and  there  is  a  tendency,  towards 
dropsy,  and  there  is  much  debility  and  anaamia,  both  may 
be  required.  Opium  should  never  be  administered,  since 
even  extremely  minute  doses  have  been  known  to  induce 
fatal  coma.  The  only  exception  to  this  rigid  exclusion, 
seems  to  be  the  simple  atrophic  kidney  of  old  age,  in  which 
opium  seems  to  be  better  borne  than  when  the  kidney  is 
contracted  by  preceding  inflammatory  changes.  And 
even  here  the  administration  of  such  preparations  as  bi- 
meconate  of  morphia  or  nepenthe  is  preferable  to  opium 
or  morphia.  A  few  drops  at  bed-time  of  these  prepara- 
tions, will  often  be  found  advantageous  to  allay  the 
annoyance  caused  by  the  frequent  nocturnal  micturition 
old  people  suffer  so  much  from. 


TBEATMENT    OF   NEPHRITIS.  271 

Patients  with  granular  Iddneys  must  be  carefully 
sheltered  from  all  atmospheric  vicissitudes.  They  should 
be  clothed  with  flannel,  their  residence  should  be  as 
sheltered  as  possible,  and  all  damp  removed  by  careful 
attention  to  the  sub- soil  drainage.  Those  who  can  afford 
it  should  live  always  in  a  warm  genial  cHmate,  with  plenty 
of  sunlight. 


272  DISEASES    OF    THE    KIDNEY. 


CHAPTEE    IV. 

SuppuBATivE     Inflammations     of     the    Kidney,    Pelvis, 
Ureters,  and  Surrounding  Tissues. 

72.  Classification. — Suppurative  inflammations  of  the 
kidney  differ  from  the  diffuse  form,  we  have  considered 
in  the  preceding  chapter,  by  the  development  of  pus,  and 
by  their  being  always  secondary  to  some  exciting  cause, 
such  as  impacted  calculi,  suppurative  disease  of  the  lower 
urinary  passages,  micro-organisms,  etc.,  whilst  both  kid- 
neys are  not  always  affected.  They  have  been  aptly 
grouped  by  Dr,  Lindsay  Steven,  into  four  classes,  whose 
classification,  with  some  slight  verbal  modification,  is  here 
adopted,  viz  : — 

Class  I.    In    M'hich  the  septic  material  is  earned    to  the  kidney  by 
means  of  the  blood.    Metastatic  abscess, 
a.  The  abscesses  are  small,  multiple  and  symmetrical,  as  in  pyesmia. 
h.  The  abscess  is  large,  may  be  confined  to  one  side,  as  sometimes 
occurs  in  ulcerative  endocarditis. 
Class  II.     In  which  the  suppuration  originates  in  disease  or  injury  of 
the  lower  urinary  passages  as  from  pyelitis,  cystitis,  etc. 

a.  The  abscess  is  large,  pyo -nephrosis,  may  result  from  impaction  of 

calculi  or  foreign  bodies  in  the  pelvis  of  the  kidney,  or  from  injury, 
or  suppurative  disease  of  the  lower  urinary  tract,  with  obstruction. 

b.  The  abscesses  are  miliary  and  multiple,  pyelo-neplirosis,  so  called 

"  surgical  kidney,"  in  which  the  infective  virus  has  gained  access 
to  the  organ,  either  by  the  urinary  tubules,  or  the  lymphatics. 

Class  III.  In  which  the  infective  material  is  brought  either  by  the 
blood,  or  by  the  lymphatics,  or  by  contiguity,  but  is  confined  to 
parts  immediately  surrounding  the  kidney,  peri-nephritis. 

Class  IV.  In  which  the  inflammation  is  set  up  by  some  specific  con- 
dition, as  in  tubercular  disease,  etc. 


PYEMIC   ABSCESSES.  273 


CiiASS  I.     Metastatic  Abscesses  of  the  Kidney. 

73.  PyaBmic  abscesses  of  tlie  kidney  are  usually 
extremely  numerous,  and  are  more  abundant  in  the  cortex 
than  in  any  other  portion  of  the  organ ;  they  nearly  always 
affect  both  kidneys.  They  present  to  the  naked  eye  the 
appearance  of  small  yellowish-white  patches,  often  some- 
what pyramidal  in  form  ;  and  surrounded  by  a  zone  of  in- 
tense hyperemia.  This  serves  to  distinguish  them  from 
the  multiple  miliary  abscesses  of  pyelo-nephrosis,  in  which 
the  zone  is  not  present  in  the  same  degree  of  intensity. 
According  to  Dr.  Steven,  if  a  section  of  the  tissue  con- 
taining the  abscess  be  examined,  the  walls  of  the  abscess 
will  be  found  ragged,  and  composed  of  round  cells  mingled 
with  red  corpuscles,  whilst  the  tubular  structure  is  infil- 
trated with  inflammatory  cells.  Occasionally  the  tubules 
have  a  glassy  homogeneous  appearance,  suggesting  the 
"  coagulation  necrosis  "  of  Weigert ;  whilst  in  the  walls  of 
the  abscess,  and  between  the  tubules,  the  capillaries  are 
often  seen  engorged.  Micro-organisms  are  invariably 
found  in  these  abscesses,  and  it  is  to  them  that  the  in- 
fective properties  of  the  embolus  are  due ;  a  point  which 
distinguishes  them  from  non-infective  infarcts,  derived  from 
aneurisms,  etc.  Pysemic  abscesses  of  the  kidney  may  occur 
during  the  progress  of  any  infective  disease,  though  as  it 
was  shown  by  the  Committee  reporting  to  the  Pathological 
Society  on  the  nature  and  causes  of  pyaemia,  septicemia, 
etc.,  they  are  less  frequent  than  in  the  lungs  or  liver  ; 
they  are  especially  observed,  however,  in  connection 
with  ulcerative  endocarditis.  The  symptoms  they  give 
rise  to  are  those  general  to  pyemia,  viz.,  rigors,  icteric 
tint  of  skin,  and  prostration,  whilst  the  fact  of  the  kidneys 


274  DISEASES    OF    THE    KIDNEY. 

being  implicated  may  escape  observation.  In  some  cases, 
however,  there  may  be  pain  in  the  renal  region  aggravated 
by  pressure,  and  the  urine  may  become  scanty,  dark 
coloured,  and  albuminous,  whilst  epithelial  and  granular 
casts  make  their  appearance,  occasionally  the  cast  is  stud- 
ded with  pus  cells,  which  display  the  characteristic  reaction 
with  acetic  acid.  The  urine  is  generally  acid,  a  condition 
which  serves  to  distinguish  pyaemic  abscess  from  pyelo- 
nephritis, which  is  alkaline. 

74,  Large  FyaBinic  Abscess  of  the  kidney  is  of  rare 
occurrence,  it  occasionally  hax^pens,  however,  that  a  larger 
embolus  than  usual  is  detached,  of  sufficient  size  to  block 
one  of  the  larger  renal  arteries.  In  these  cases,  however, 
necrosis  rather  than  purulent  destruction  is  generally  the 
result.  Thus  in  a  case,  recorded  by  Bartels,  of  a  boy  eight 
years  old,  the  left  kidney  was  completely  necrosed  from 
an  extensive  embolism  caused  by  large  thrombus  masses 
existing  in  the  left  ventricle  of  the  heart.  If,  however, 
the  embohsm  is  infective,  as  in  ulcerative  endocarditis,  it 
will  give  rise  to  abscess  instead  of  necrosis.  Thus  in 
a  case  related  by  Vogel,  the  whole  of  one  kidney  was 
destroyed  by  suppuration,  without  any  other  anomaly 
being  found  in  the  uropoetic  system.  Maier  also  records  a 
case  in'  which  it  was  noted  that  a  large  embolus  had 
plugged  the  right  renal  artery,  leading  to  the  formation  of 
a  large  renal  abscess,  in  which  numerous  bacteria  were 
discovered.  No  special  treatment  is  called  for  when 
pysemic  abscesses,  either  large  or  smaU,  form  in  the  kid- 
neys, it  is  the  general  septic  condition  that  must  be 
combatted.  The  strength  must  be  supported  by  beef  tea 
and  stimulants,  whilst  antiseptic  medicines,  such  as  qui- 
nine, boracic  acid,  sulpho-carbolates,  etc.,  should  be  ad- 
ministered. 


PYELITIS    AND    PYO-NEPHEOSIS.  275 


Class  II.     Pyelitis  and  Pyo-nepheosis, 

75.  Symptoms. — luflammation  of  the  mucous  mem- 
brane of  the  pelvis  of  the  kidney  is  termed  pyelitis.  Should, 
however,  the  ureter  of  the  affected  kidney  become  blocked 
so  that  the  discharge  of  urine  is  prevented,  a  collection  of 
purulent  fluid  mixed  with  secreted  urine,  takes  place  above 
the  obstruction,  greatly  distending  the  pelvis  of  the  affected 
kidney,  and  forming,  more  or  less,  a  palpable  tumour,  this 
condition  is  spoken  of  as  fyo-yiephrosis.  The  change  in 
the  character  of  the  urine  is  the  leading  symptom.  In 
an  early  stage,  the  urine  is  generally  acid,  and  varies 
but  little  in  quantity  and  specific  gravity,  it  is,  how- 
ever, turbid,  and  on  standing,  yields  an  abundant  sedi- 
ment, consisting  of  epithelial  cells,  pus  globules,  and 
in  acute  cases,  or  those  associated  with  renal  calculus, 
blood  corpuscles.  At  this  stage  it  is  possible  to  make  out 
by  microscopic  examination,  the  characteristic  epithehum 
cells  of  the  renal  pelvis.  These  are  (fig.  15,  p.  136)  spindle- 
shaped,  caudate,  and  laminated,  and  are  usually  more 
swollen  than  normal,  a  condition  which  distinguishes  them 
from  somewhat  similar  cells  from  other  portions  of  the 
genito-urinary  tract.  As  the  quantity  of  pus  increases  with 
the  progress  of  the  disease,  this  characteristic  epithelium  is 
lost  sight  of.  The  urine  contains  albumin,  which  however, 
unless  there  is  co-existent  kidney  disease,  is  derived  from 
the  pus  and  the  blood,  when  that  element  is  present.  In 
old  standing  cases,  especially  in  those  in  which  the  disease 
originated  in  the  mucous  membrane  of  the  lower  urinary 
organs,  and  has  crept  upwards,  the  urine  may  become  am- 
moniacal.  This  alkaline  condition  of  the  urine  dissolves 
the  pus  corpuscles,  and  they  are  no  longer  deposited  in  a 
creamy  layer,  but  the  whole  urine  becomes  opaque  and 

t2 


276  DISEASES    OF    THE    KIDNEY. 

viscous,  whilst  abundant  crystals  of  ammonium-magne- 
sium phosphate  (fig.  10,  p.  96),  together  with  numerous 
bacteria,  form  in  it.  If  no  obstruction  exists  at  the  orifice 
of  the  ureter,  the  purulent  urine  is  passed  continuously, 
the  desire  to  micturate  being  frequent.  But  when  any 
obstruction  occurs  in  the  urinary  passages,  the  discharge 
is  either  entirely  suppressed,  or  it  comes  intermittently,  as 
the  obstruction  from  time  to  time  is  overcome.  The  accu- 
mulation of  pus  in  the  pelvis  of  the  kidney,  leads  to  the 
formation  of  a  renal  tumour,  which  generally  is  most 
prominent  in  the  flank,  extending  downwards  and  for- 
wards. When  with  this  tumour  we  have  an  intermittent 
discharge  of  muco-purulent  urine,  or  there  has  been  such 
a  discharge,  the  diagnosis  of  pyo-nephrosis  is  not  difficult, 
and  it  only  becomes  so,  when  we  have  no  evidence  of  a 
previously  existing  purulent  state  of  the  urine. 

The  pain  in  pyelitis  is  not  generally  severe,  and  is 
usually  hmited  to  an  aching  feeling  across  the  loins.  It 
is,  however,  often  reflected,  and  UTitability,  which  in 
some  cases  may  amount  to  strangury,  may  be  felt  in  the 
bladder,  and  along  the  urethra.  The  pyrexia  in  simple 
pyelitis  is  rarely  high,  but  when  pus  accumulates  in  the 
pelvis  as  in  pyo-nephrosis,  the  rigors  become  more  marked, 
and  recur  more  frequently. 

76.  Etiology. — Exposure  to  cold  and  wet,  especially  if 
there  be  any  existing  disease  of  the  lower  urinary  organs, 
as  gonorrhcea,  or  chronic  vesical  catarrh.  The  adminis- 
tration of  irritating  medicines  in  large  doses,  as  turpen- 
tine, cantharides,  copaiba,  etc.,  though  these  in  moderate 
quantities  are  often  given  as  remedies  in  the  complaint, 
may  induce  pyehtis.  But  the  two  most  fertile  causes  of 
the  disease,  are  to  be  found  in  the  irritation  of  foreign 
bodies  or  growths  in  the  pelvis  of  the  kidney,  and  obstruc- 
tion to  the  regular  flow  of  urine.     In  the  first  category, 


PYELITIS    AND    PYO- NEPHROSIS.  277 

renal  calculus  is  the  most  frequently  observed,  whilst  less 
rarely  the  irritation  is  caused  by  mahgnant  growths, 
tubercular  deposits,  hydatids,  or  blood  clots,  the  result  of 
hffimorrhages.  In  the  second  list,  ai.y  obstructive  disease 
of  the  lower  urinary  passages,  such  as  stricture  of  the 
urethra,  enlarged  prostate,  chronic  vesical  catarrh,  phi- 
mosis, sooner  or  later  induces  inflammation  of  the  mucous 
surface  of  the  renal  pelvis.  In  spinal  disease  attended 
with  paraplegia,  the  mucous  surface  of  the  pelvis  of  the 
kidney  participates  in  the  change,  common  to  the  whole  of 
the  mucous  membrane  of  the  genito-urinary  tract,  and 
which  is  attended  with  ammoniacal  decomposition  of  the 
urine  (p.  65).  Pyelitis  occurs  in  many  constitutional 
affections.  Thus  it  is  often  noticed  in  gouty  individuals, 
caused  no  doubt  by  the  lithatic  condition  of  their  urine. 
Scrofulous  deposit  in  the  mucous  tract  gives  rise  to  the 
most  intractable  form  of  pyelitis.  In  Bright's  disease,  and 
in  diabetes,  slight  inflammation  of  both  renal  pelves  is  gen- 
erally present.  It  may  also  develop  during  the  progress  of 
enteric,  scarlet,  and  typhus  fevers,  small-pox,  measles, 
cholera,  scurvy,  and  pregnancy. 

77.  Diagnosis. — We  have  to  distinguish  first  between 
pyelitis  and  vesical  catarrh  ;  secondly,  when  the  latter  is 
present,  to  ascertain  whether  the  renal  pelves  are  affected 
as  well.  The  discovery  in  abundance  of  the  swollen  epi- 
thelial cells,  peculiar  to  the  renal  pelvis,  in  the  urine,  af- 
fords a  tolerably  certain  indication  of  the  existence  of 
pyelitis,  but  when  they  are  no  longer  to  be  found,  we  must 
rely  on  general  symptoms  to  distinguish  between  inflam- 
mation of  the  upper  and  lower  urinary  tract.  In  pyelitis 
the  urine  is  decidedly  more  purulent  and  acid  than  in 
vesical  catarrh,  which  is  usually  muco -purulent  and  fre- 
quently alkaline,  from  ammoniacal  decomposition  of  the 
urine.     When  both  pyelitis  and  vesical  catarrh  co- exist, 


278  DISEASES    OF    THE    KIDNEY. 

the  amount  of  pus  passed  "with  the  urine  is  more  con- 
siderable, and  in  addition  to  kimbar  pain  symptoms  of 
vesical  m-itation  are  present.  In  pyo -nephrosis,  when  a 
tumour  is  formed,  we  have  to  distinguish  it  from  malig- 
nant growths,  hydatids,  and  hydro-nephrosis.  In  these 
there  is  an  absence  of  pyrexia;  whilst  the  cessation,  or  in- 
termittent discharge,  of  previously  existing  purulent  urine, 
also  serves  to  distinguish  it. 

78.  Morbid  Anatomy. — In  the  earlier  stages,  the 
mucous  membrane  of  the  pelvis  of  the  affected  kidney  is 
reddened  and  swollen,  and  covered  with  a  muco-purulent 
discharge.  In  cases  when  the  disease  is  secondary  to 
some  constitutional  disturbance  as  for  instance  in  puerperal 
fever,  small  sloughs,  which  appear  as  minute  yellow  spots, 
may  form  on  the  surface  of  the  mucous  membrane.  "When 
the  disease  has  become  chronic,  the  mucous  membrane  will 
be  found  thickened  and  of  an  ashy  colour.  This  condition 
may  last  a  considerable  time  without  the  renal  structure 
being  affected,  but  ultimately  the  effects  of  pressure  be- 
come manifest,  and  the  infundibula  become  dilated,  and 
the  papilla  flattened ;  whilst  the  process  of  dilatation  may 
proceed  to  the  complete  obliteration  of  the  cortex,  and  the 
conversion  of  the  kidney  into  a  mere  bag  of  pus.  The 
rapidity  and  'extent  of  this  change  depend  of  course  on 
the  degree  and  amount  of  obstruction  that  exists  at  the 
outlets  of  the  renal  pelvis.  When  this  arises  only  from 
the  thickened  state  of  the  mucous  membrane  and  is 
not  complete,  the  dilatation  and  destruction  of  the  kid- 
ney take  place  slowly,  and  never  proceed  to  an  extreme 
degree.  On  the  other  hand,  when  a  calculus  or  other 
foreign  body  absolutely  obstructs  the  flow  of  purulent 
uriae  down  the  ureter,  the  destruction  of  the  kidney  is 
generally  rapid  and  more  or  less  complete.  The  effect  of 
pressure  in  the  urinary  tubules  is  first,  to  cause  an  over- 


PYELITIS    AND    PYO-NEPHROSIS.  279 

growtli  of  tlie  connective  tissue,  a  conservative  process 
whicli  enables  the  kidney  for  a  time  to  resist  the  stretching 
which  its  tubular  structure  undergoes  ;  gradually,  how- 
ever, absorption  of  the  pyramidal  portion  of  the  kidney 
proceeds,  the  situation  of  the  absorbed  portion  being 
represented  by  the  expanded  calix.  The  cortex  resists  the 
pressure  some  time  longer,  owing  probably  to  considerable 
overgrowth  of  interstitial  connective  tissue.  This  ulti- 
mately becomes  thinned  and  stretched,  so  that  the  whole 
kidney  resembles  a  large  cyst.  The  tumour,  thus  formed, 
may  be  converted  into  a  semi- solid  mass  by  the  drying  up 
of  the  purulent  fluid  which  mingled  with  the  urinary  salts 
forms  a  putty-like  material ;  or  the  purulent  fluid  may  be 
absorbed,  in  which  case  the  tumour  becomes  reduced  in  size 
if  not  altogether  shrivelled  up  ;  or  the  tumour  may  burst, 
posteriorly  into  the  renal  cellular  tissue  and  thus  set  up 
peri-nephritis  or  anteriorly  into  the  bowels,  or  pass  down- 
wards into  the  iliac  fossa  along  the  psoas  muscle  and  form 
an  abscess  in  Scarpa's  triangle  ;  or  what  is  far  less  com- 
mon may  find  its  way  upwards  to  the  lungs  and  burst  into 
the  bronchial  tubes,  whilst  equally  rare  is  rupture  into 
the  peritoneum. 

79.  Prognosis.— Idiopathic  j)yelitis  when  properly 
treated  is  rarely  an  obstinate  or  prolonged  affection,  it  is 
only  when  associated  with  long  standing  disease  of  the 
lower  urinary  organs,  or  the  presence  of  foreign  bodies  in 
the  pelvis  of  the  kidney,  that  it  becomes  formidable.  The 
improvements  in  renal  surgery  of  late  years,  however,  have 
considerably  diminished  the  fatality  of  these  cases,  and 
operations  for  the  relief  of  pyo-nephrosis  are  readily  under- 
taken at  a  period  when  there  is  the  best  chance  for  the 
patient's  recovery,  and  before  the  complete  destruction  of 
the  kidney  has  taken  place. 

80.  Treatment.— In  the    treatment    of    pyelitis  its 


280  DISEASES    OF    THE    KIDNEY. 

origination  must  hold  tlie  foremost  place  of  consideration. 
If  due  to  simple  catarrh,  or  to  any  temporary  constitu- 
tional disturbance,  rest  in  bed,  diluent  drinks  and  alkaline 
saline  remedies' are  sufficient  to  subdue  the  inflammation. 
If  after  the  pain  and  fever  has  subsided  the  urine  still 
continues  cloudy,  the  chronic  catarrh  will  be  best  removed 
by  the  administration  of  benzoic  acid  and  terebinthine 
remedies.  I  have  found  these  more  reliable  and  more  effi- 
cacious than  either  tannic  acid,  iron,  or  the  mineral  acids 
which  have  been  recommended.  In  calculous  pyehtis  our 
object  must  be  to  remove  the  foreign  body  as  quickly  as 
possible,  this  can  either  be  done  by  attempting  its  solution 
by  medical  means  or  by  operative  interference.  In  pyo- 
nephrosis, if  the  discharge  from  the  kidney  is  intermittent 
we  may  hope  the  obstruction  will  pass ;  for  this  purpose,  the 
renal  passages  shovild  be  got  into  as  healthy  a  state  as 
possible,  and  turpentine  given  with  biborate  of  soda  if  the 
urine  is  acid,  or  with  boracic  acid  if  it  is  alkaline,  is  un- 
doubtedly the  most  efficacious  ;  whilst  diluents,  of  which 
distilled  water  is  as  good  as  any,  owing  to  its  diuretic  ac- 
tion, should  be  freely  given.  At  the  same  time  the  patient 
should  have  complete  rest  on  a  sofa  or  better  still  on  a 
specially  constructed  couch.  If  a  tumour  should  form, 
the  question  of  operative  procedure  must  be  raised  at  an 
early  period.  Should  it  be  objected  to  by  the  patient,  we 
must  hope  by  maintaining  the  general  health,  that  the  con- 
tents of  the  tumour  may  solidify  or  become  absorbed. 
The  chronic  pyelitis  of  gouty  individuals,  or  those  suffer- 
ing from  oxaluria,  and  which  often  runs  an  insidious 
course,  is  greatly  benefitted  by  direct  treatment  of  the  di- 
gestive organs,  such  as  alkalies  in  the  one  case,  and  nitro- 
muriatic  acid  in  the  other,  and  by  drinking  the  mineral 
waters  of  Vichy  and  Contrexeville  respectively.  Should 
an  operation  be  decided  on  for  the  relief  of  unilateral  pyo- 


PYELITIS    AND    PYO-NEPHROSIS.  281 

nephrosis,  the  question  of  the  condition  of  the  other  kidney 
has  to  be  considered. 

The  best  means  of  ascertaining  whether  this  is  in  a 
healthy  condition  or  not,  and  this  is  required  in  cases 
in  which  nephrectomy  or  nephrotomy  is  called  for,  is 
I  believe,  by  introducing  Mr.  Davy's  rectal  lever  into 
the  rectum,  having  previously  emptied  the  bladder,  and  to 
compress  the  ureter  of  the  diseased  side,  so  as  to  prevent 
the  passage  from  it  of  even  a  small  quantity  of  purulent 
urine,  then  the  urine  passed  during  that  period  by  the  other 
kidney  will  furnish  us  with  a  very  tolerable  idea  of  the 
state  of  things  there.  If  normal,  no  further  enquiry  need 
be  made,  but  as  it  sometimes  contains  traces  of  pus,  and 
albumin,  derived  from  the  bladder,  a  more  rigid  examina- 
tion into  its  constitution  may  be  required.  Diminution  in 
the  amount  of  urea  excreted  must  not  be  regarded  in  itself 
as  sufficient  to  debar  an  operation,  since  in  most  chronic 
diseases  the  elimination  of  urea  is  diminished,  but  what  is 
of  serious  import,  is  for  the  urea  to  be  diminished  out 
of  proportion  to  the  inorganic  constituents.  Thus,  in 
normal  urine  of  the  twenty-four  hours,  the  relationship 
of  urea  to  the  inorganic  constituents  may  be  stated  as 
2-3  :  1"6,  but  suppose  we  find  in  any  given  case  the  per- 
centage of  the  urea  falls  considerably  below  this,  whilst 
the  inorganic  are  relatively  but  little  affected,  we  may 
fairly  assume  that  structural  alterations  in  the  kidneys 
exist,  which  are  the  cause  of  the  deficient  elimination  of 
nitrogen,  whilst  the  salts  and  water  are  still  transmitted. 
Even  this  cannot  be  entirely  relied  on,  though  taken  in 
conjunction  with  other  evidence  it  often  affords  us  assist- 
ance in  arriving  at  a  right  conclusion. 


282  DISEASES    OF    THE    KIDNEY. 


Pyelo-Nephrosis   (Consecutive  Nephritis,  Beck). 

81.  Etiology. — The  morbid  conditions  of  the  kidney, 
the  consequence  of  vesical  or  urethral  disease  have  been 
classified  by  Beck  as  follows  : — 1.  The  effects  of  pressure 
caused  by  obstructions  of  the  urinary  passages.  2.  Dif- 
fuse interstitial  inflammation.  3.  Interstitial  inflamma- 
tion with  scattered  points  of  suppuration.  4.  The  cica- 
tricial kidney,  noticed  in  cases  that  recover.  Although 
these  conditions' are  readily  distinguishable  from  each  other, 
still  it  is  more  common  to  find  them  existing  together, 
and  therefore  they  must  be  considered  as  forming  one 
disease.  These  conditions,  which  till  Beck's  masterly 
description,  were  very  imperfectly  understood,  have  in 
consequence  of  their  frequent  association  with  pyelitis, 
been  classed  together  under  the  term  ijyelo-nephrosis.  This 
designation  is  retained  here  for  convenience,  though  the 
name  consecutive  nephritis  as  proposed  by  Beck  is  un- 
doubtedly more  correct.  The  changes  in  the  kidney  are 
distinguished  from  those  occurring  in  pyemia,  by  their 
being  confined  to  the  renal  structure,  and  by  being  invari- 
ably associated  (with  one  exception),  to  disease  of  the 
lov/er  urinary  organs,  so  that  they  may  be  regarded  as  the 
result  of  a  local  infective  process.  They  constitute  the 
most  frequent  terminations  of  old  urinary  cases,  and 
recently  special  attention  has  been  drawn  to  fhem  by  Sir 
Andrew  Clark  in  his  paper  read  before  the  Medical  Society, 
Dec.  1883. 

The  chief  causes  concerned  in  the  production  of  secondary 
renal  disease,  are  according  to  Beck  : — 1.  Increased  urinary 
pressure,  causing  chronic  interstitial  inflammation,  and 
gradual  absorption  of  the  structure  of  the  pyramids.  This 
pressure  rarely  arises  from  regurgitation  from  the  bladder, 


PYELITIS    AND    PYELO-NEPHKOSIS. 


283 


but  is  invariably  connected  with  obstruction  of  tlie  ure- 
ters, the  most  common  form  being,  the  pressure  on  the 
ureters  of  the  thick  bundles  of  muscular  tissue  of  an 
hypertrophied  bladder,  such  as  we  find  in  old  standing 
stricture  of  the  urethra,  enlarged  prostate,  or  from  vesical 
calculus.  If  in  these  ■  cases  the  pressure  came  from  in 
front,  we  should  find  the  changes  similar  in  both  kidneys, 
but  as  they  are  frequently  different,  it  is  natural  to  assume 
that  the  cause  of  the  difference  lies  in  the  unequal  degree 
of  obstruction  existing  at  the  orifices  of  the  two  ureters. 
2.  Reflex  irritation  of  the  kidney. — A  close  nervous  relation 
seems  to  exist  between  the  trigone  of  the  bladder,  and  the 
prostatic  and  bulbous  portions  of  the  urethra.  Irritation  of 
the  nerves  of  these  parts,  therefore,  probably  sets  up  a  cer- 
tain degree  of  hyperaemia.  This,  if  the  kidneys  are  healthy, 
is  comparatively  harmless,  but  if  they  have  already  be- 
come the  seat  of  diseased  action,  then  the  irritation  tends  to 
aggravate  any  inflammatory  changes  that  may  have  been 
set  up.  3.  Presence  of  septic  matters. — In  the  majority  of 
cases,  the  presence  of  decomposing  urine  in  the  pelvis  of 
kidney  is  the  immediate  exciting  cause  of  the  acute 
attack,  and  the  mode  in  which  it  acts,  is  as  Beck  suggests 
as  follows  :  the  pelvis  of  the  kidney,  and  probably  also  the 
straight  tubules  for  a  greater  or  less  distance  are  filled 
with  putrid  urine  at  some  degree  of  pressure,  the  contact 
of  this  irritating  fluid,  damages  the  epithelium,  and  causes 
its  desquamation,  the  septic  matter  then  passes  into  the 
inter-tubular  lymph  spaces  of  the  kidney,  and  excites 
diffuse  inflammation,  which  spreads  rapidly  tov/ards  the 
cortex  and  between  the  tubules.  But  it  may  occur,  as 
Klebs  has  pointed  out,  without  there  being  any  continuity 
of  the  inflammation  with  that  in  the  bladder,  and  the 
question  then  arises  how  the  infective  matter  reaches  the 
kidney.     Klebs   has   accounted  for   it  by    showing  that 


284 


DISEASES    OF    THE    KIDNEY. 


organisms  might  spread  up  into  the  tubules  of  the  kidney, 
and  so  excite  the  suppurative  action.  Whilst  Dr.  Lindsay 
Steven  has  shown  how  the  infective  virus  may  gain  access 
to  the  kidney  from  the  bladder,  apart  from  the  route  by  the 
tubules,  viz.,  by  means  of  the  lymphatic  spaces  through 
the  bladder  wall,  the  organisms  gaining  access  to  the 
lymphatic  channels  in  the  walls  of  the  ureters,  and  thus 
gradually  spread  upwards.  At  length  the  organisms  reach 
the  pelvis  of  the  kidneys,  and  then  pass  into  the  lymphatic 
spaces  of  the  capsules,  giving  rise  to  small  abscesses.  The 
fact  that  abscesses  are  so  frequently  met  with,  situated 
between  the  capsule  and  the  kidney,  and  the  elongated 
and  pyramidal  shape  assumed  by  the  inflammatory  pro- 
cesses when  extending  through  the  cortex  are,  as  Dr. 
Steven  remarks,  strongly  suggestive  of  the  infective 
material  being  disseminated  through  the  kidneys  by  the 
lymphatic  vessels.  It  is  not  improbable  that  the  fre- 
quency with  which,  according  to  Mr.  Doran's  recent  obser- 
vations, pyelo-nephrosis  is  found  post-mortem  after  opera- 
tions on  the  internal  generative  organs,  may  be  due  to  this 
cause. 

Catheterism  is  often  the  immediate  exciting  cause  of 
pyelo-nephrosis,  and  the  danger  resulting  from  its  employ- 
ment is  certainly  greater  when  the  practice  is  first  begun, 
than  when  the  patient  has  become  habituated  to  its  use. 
Pyelo-nephrosis  also  frequently  follows  on  operations  per- 
formed on  any  portion  of  the  lower  urinary  tract.  Mr. 
Alban  Doran  [op.  cit.)  has  also  shown  that  it  not  infre- 
quently follows  on  operations  on  the  internal  genital 
organs,  in  these  cases  the  renal  mischief  may  be  excited 
by  reflex  irritation,  since  a  close  connection  seems  to 
subsist  between  the  kidneys  and  internal  organs  of  gene- 
ration and  their  appendages,  as  shown  by  Dr.  Matthews 
Duncan  [Med.  Chir.  Trans.,  1884)  in  the  frequent  associa- 


PYELITIS   AND    PYELO-NEPHROSIS.  285 

tion  of  albuminuria  with  parametritis.  But  as  iu  most 
of  Mr.  Doran's  cases,  chronic  interstitial  changes  were 
noticed,  it  is  not  improbable  that  some  degree  of  obstruc- 
tion to  the  flow  of  urine  had  previously  existed,  due  to 
pressure  of  the  tumour  on  the  ureters,  which  may  have 
predisposed  to  the  intense  renal  hyperemia  which  ensued 
when  operative  procedures  were  undertaken.  In  some 
cases,  however,  though  this  has  not  been  actually  ob- 
served, septic  virus  may  have  been  conveyed  by  the  lym- 
phatics of  the  ovaries,  etc.,  to  the  kidneys. 

But  it  is  not  always  necessary  for  operative  pro- 
cedures to  excite  the  secondary  renal  mischief,  given 
obstructive  inflammatory  disease  of  the  lower  urinary 
passages,  any  slight  disturbing  influence  may  start 
the  ]3rocess.  Thus  I  have  seen  it  follow  upon  a  chill, 
caught  by  sitting  in  wet  clothes,  in  a  patient  suffering 
from  gleet,  and  who  also  had  a  stricture  of  the  urethra. 
And  in  another  instance,  which  I  saw  last  summer  with 
Mr.  Elliot  of  Belvedere,  the  immediate  cause  appeared  to 
be  enforced  retention  during  a  long  railway  journey. 

82.  Morbid  Anatomy. — The  chronic  interstitial  ne- 
phritis, which  results  as  we  have  seen  (p.  279)  from  the 
effect  of  pressure,  is  intermixed  in  difl'erent  degrees,  in 
the  kidney,  which  has  become  the  seat  of  suppurative 
nephritis,  with  diffuse  interstitial  inflammation,  more  or 
less  acute,  and  scattered  points  of  suppuration.  The 
kidney  is  enlarged,  often  only  slightly,  and  its  sub- 
stance softened.  The  capsule  strips  oif  easily,  but  tear- 
ing the  surface  in  places,  especially  over  the  seat  of 
small  collections  of  pus.  Scattered  over  the  surface 
of  the  organ  are  yellow  spots,  surrounded  by  a  red 
zone,  either  containing  pus  or  excessively  soft ;  between 
these  yellow  spots  the  kidney  substance  is  of  a  palish-yel- 
low colour,  mottled  with  red.    On  section,  purulent  soften- 


286  DISEASES    OF    THE    KIDNEY. 

ing  will  be  observed,  giving  the  cortex  a  mottled  appear- 
ance. Tbe  small  purulent  collections,  like  yellow  streaks, 
extend  from  tbe  superficial  abscesses  into  the  cortex,  whilst 
others  are  observed  in  the  pjTamids,  which  follow  the 
course  of  the  interfasicular  veins,  and  are  therefore  in  the 
line  of  the  lymphatics.  This  purulent  softening  has  a 
somewhat  wedge-shaped  appearance,  and  may  have  distinct 
centres  of  suppuration ;  they  may  also  be  surrounded  by  a 
slight  zone  of  hypersemia,  but  this  is  never  so  intense  as 
with  embolic  abscesses.  Another  point  that  serves  to 
distinguish  them  from  embolic  abscess,  is  that  in  the 
latter  the  width  of  the  base  is  seldom  less  than  half  its 
length,  whilst  in  these  abscesses  the  base  showing  on  the 
surface  may  be  only  the  width  of  a  pin's  head,  while  the 
length  of  the  wedge  may  be  an  inch  or  more.  Yellowish 
lines  may  also  be  observed,  extending  from  the  papiUffi  to 
the  base  of  the  pyramids,  which  correspond  to  small  foci 
of  suppuration,  extending  in  the  dhection  of  the  urini- 
ferous  tubules.  The  pelvis  of  the  kidney  is  often  intensely 
inflamed. 

On  microscopic  examination,  areas  of  interstitial  in- 
flammation will  be  found  both  in  the  cortex  and  jDyramids. 
In  the  parts  most  distant  from  the  centre  of  suppuration, 
only  small  round  cells  will  be  observed  between  the 
tubules ;  the  epithehum  is  shghtly  swollen  and  cloudy,  but 
the  nuclei  of  cells  are  readily  seen  without  reagents.  In 
the  next  stage  the  tubules  are  invaded  by  the  round  cells, 
the  renal  epithelium  being  still  distinctly  recognisable. 
Finally  all  trace  of  tubule  and  epithelium  disappears,  their 
place  being  occupied  by  smaU  round  ceUs,  which  after  the 
breaking  down  of  the  intercellular  substance,  become  pus 
(fig.  27). 

A  careful  microscopic  search  according  to  the  method 
described  by  Dr.  Lindsay  Steven,   wiU  generally  reveal 


PYELITIS   AND    PYELO-NEPHEOSIS. 


287 


micro-organisms,  either  disseminated  or  grouped  together 
into  colonies  or  zoogloea.  The  colonies  are  usually  asso- 
ciated with  one  of  the  inflammatory  foci,  although  some- 
times there  is  no  ajDparent  relationship,  and  they  are  often 
as  abundant  in  the  pyramidal  as  the  cortical  portion,  but 
in  the  former  situation  the  zoogloea  are  elongated,  in  tho 


■^^^  *^J*^^ 


i^ 


Fig.  27. — ShowiDf^,  on  one  side,  the  inter-tubular  infiltration,  and  in- 
vasion of  tubules  with  round  cells  ;  on  the  other,  the  breaking  down 
of  the  intercellular  substance  (Erichsen's  Surgery). 


latter,  somewhat  circular  in  shape.  When  the  virus  is 
situated  within  the  uriniferous  tubules,  the  colonies  may 
often  be  seen  to  be  directly  continuous  with  epithehum, 
or,  in  transverse  section,  surrounded  by  it,  as  is  shown  in 
fig.  28.  When  the  organisms  are  contained  in  the  lym- 
phatics no  such  evidence  of  intra-tubular  situation  is  to  be 
found.  No  micrococci  have  been  found  in  the  glomeruli 
or  other  vessels,  a  fact  which  Dr.  Steven  believes  dis- 
tinguishes this  condition  from  the  state  of  matters  ob- 
served in  metastatic  abscess  of  the  kidney. 

Should    the    process    subside,    the    kidney    becomes 
shrunken,  toughened,  and  irregular  in  form    {cicatricial 


288 


DISEASES    OF    THE    KIDNEY. 


kidney) ,  closely  resembling  the  granular  contracted  kidney. 
Occasionally  cicatrices  are  to  be  observed  on  the  surface, 
probably  the  scars  of  former  abscesses.  Kidneys  that 
have  undergone  this  change,  may,  however,  become  the 
seat  of  another  acute  attack,  so  that  chronic  and  acute 
changes  are  found  variously  combined. 


Fig.  28. — Transverse  section  showing  colonies  of  micrococci  in  two  of  the 
tubules  of  the  kidney  (Dr.  Lindsay  Steven). 


83.  Symptoms. — Suppurative  nephritis  is  ushered  in. 
■with  marked  rigors,  sometimes  so  severe  as  to  simulate  an 
attack  of  ague.  Indeed,  in  a  case  I  saw  recently  with  Mr. 
Parsons  of  Hackney,  we  had  some  little  difficulty  at  first 
in  arriving  at  a  decision.  The  patient  had  suffered  much 
from  ague,  he  had  also  an  enlarged  prostate.  As  the  urine 
contained  pus,  the  question  arose  whether  the  rigors  were 
associated  with  renal  mischief,  or  were  purely  malarial. 


PYELITIS    AND    PYELO-NEPHRITIS.  289 

The  latter  conclusion  was  arrived  at  since  the  amount  of 
urea  excreted  was  in  excess,  and  the  reaction  of  the  urine 
acid.  What  added  to  our  difficulty  in  this  case  was  the 
fact  that  in  addition  to  the  rigors  and  pyuria,  the  patient 
was  decidedly  heavy  and  drowsy,  and  had  somewhat  an 
icteric  tint;  he,  however,  recovered.  Following  the  rigor, 
ursemic  convulsions  may  ensue;  though  according  to  Beck 
ursemic  convulsions  or  coma  are  usually  absent  in  these 
cases.  In  one  case,  however,  I  was  called  to  see,  com- 
plete coma  lasting  several  hours, followed  the  initial  rigor; 
the  patient  survived  this  attack  fourteen  days,  during  the 
interval  he  lay  in  a  dreamy  state,  but  not  quite  uncon- 
scious. The  urine  is  not  usually  diminished  in  quantity, 
but  the  amount  of  urea  excreted  if  altered  at  all,  is  below, 
rather  than  above,  the  normal,  whilst  the  reaction  is  al- 
most invariably  alkaline.  Albumin,  unless  there  is  much 
pus  or  blood,  is  not  abundant.  The  urine  deposits  much 
epithelium,  renal  and  vesical,  occasionally  hyaline  and 
granular  casts,  sometimes  pus  casts.  Pain  in  the  loins 
may  be  complained  of,  especially  on  j)ressure,  but  is 
rarely  severe  ;  when  it  is,  it  points  to  extension  of  the  in- 
flammation to  the  cellulo-adipose  tissue — peri-nephritis. 
Among  the  general  symptoms  may  be  noted  rapid  emacia- 
tion, gastric  disturbance,  nausea,  sometimes  urgent  vomit- 
ing, and  diarrhoea,  an  icteric  tint  of  the  skin  is  developed 
early.  As  the  end  approaches,  the  tongue  becomes  brown 
and  dry,  the  pulse  remarkably  rapid,  feeble,  and  inter- 
mitting, the  patient  lies  in  a  dreamy  state,  sometimes 
accompanied  with  a  muttering  delirium,  and  often  bathed 
in  a  profuse  sweat,  the  temperature  sometimes  before  death 
becomes  sub-normal.  In  this  state  he  may  remain  many 
days,  it  is  rare,  however,  for  the  patient  to  survive  three 
weeks  from  the  first  rigor,  more  frequently  death  occurs 
within  a  few  days.     The  disease  when  it  comes  on  insidi- 

u 


290  DISEASES    OF    THE    KmNEY. 

ously  may  be  taken  for  general  pyaemia,  typhoid  fever, 
septic  peritonitis,  or  ague.  In  all  cases  an  examination  of 
the  urine  will  help  to  decide  the  question.  If  the  urine 
be  ammoniacal,  purulent,  and  the  urea  not  in  excess,  and 
there  is  also  existing  disease  of  the  lower  urinary  organs, 
the  matter  ought  not  to  be  doubtful. 

84.  Treatment. — Since  in  the  cicatricial  kidney,  old 
scars  the  result  of  past  abscesses  in  the  kidneys  have  been 
found  post-mortem,  we  may  infer  that  the  disease  is  not 
always  immediately  fatal.  We  must  not  therefore  abandon 
these  cases  in  despair.  The  indications  for  treatment  are 
twofold,  first  to  support  the  patient's  strength,  and  secondly 
to  combat  the  local  septic  conditions.  Tlie  first  indication  is 
best  fulfilled  by  dietetic  measures,  and  attention  should  be 
paid  to  the  condition  of  the  alimentary  canal,  and  the  bowels 
should  be  freely  reheved.  If  diarrhoea  exists,  the  adminis- 
tration of  a  purgative  is  not  contra-indicated,  since  the 
diarrhoea  is  evidently  eliminative,  and  not  due  to  inflam- 
matory conditions  in  the  intestines,  but  mild  purgatives 
must  be  employed,  such  as  castor  oil,  to  which  a  few  drops 
of  laudanum  may  be  added.  Should  there  be  vomiting  as 
well,  then  three  or  four  gi-ains  of  calomel  dusted  on  the 
tongue  is  indicated.  After  the  action  of  the  oil  or  calomel, 
the  tendency  to  diarrhoea  will  often  diminish,  whilst  the 
patient  will  be  less  drowsy.  "With  regard  to  antiseptic 
remedies,  our  chief  reliance  must  be  placed  in  quinine  and 
boracic  acid.  The  latter  has  the  advantage  possessed  by 
few  other  antiseptic  remedies  of  passing  unchanged 
through  the  kidneys,  it  therefore  acts  upon  the  whole 
urinary  tract.  It  can  be  given  in  large  doses.  As  it  is 
very  insoluble,  the  foUowiug  prescription  will  be  found 
the  best  mode  of  administering  it.  Dissolve  boracic  acid 
3  ij.,  in  glycerine  |  j.,  add  to  this  hot  water  J  viii.,  flavoured 
with  syruiJ  of  orange  peel.    Of  this  mixture  take  one  ounce 


PYELITIS   AND    PYELO-NEPHBITIS.  291 

four  times  daily.  Turpentine  may  also  be  advantageously 
employed  with  boracic  acid.  It  certainly  improves  the  con- 
dition of  the  urine,  whilst  its  administration,  for  a  time, 
seems  to  rouse  the  patient.  Owing  to  their  toxic  action,  iodo- 
form and  the  salicylates,  should  not  be  given.  The  ques- 
tion whether  the  bladder,  if  diseased,  should  be  washed  out 
after  consecutive  nephritis  has  occurred,  may  arise.  Some 
have  thought  the  introduction  of  the  catheter  keeps  up 
reflex  irritation,  and  thus  adds  to  the  renal  hyperaemia. 
But  it  seems  to  me  that  there  is  less  risk  in  completely 
emptying  the  bladder,  than  in  allowing  foul  urine  to  accu- 
mulate, and  if  a  catheter  be  introduced  I  do  not  see  why, 
when  the  urine  is  withdrawn  an  antiseptic  should  not  be 
introduced.  For  this  purpose,  thirty  grains  of  boracic  acid 
in  four  ounces  of  water,  or  a  0*2  per  cent,  solution  of  hydro- 
chloric acid,  or  quinine  are  the  best  solutions  to  employ. 
The  patient's  strength  must  be  supported,  but  in  order  to 
diminish  the  excretion  of  nitrogen  by  the  kidney,  albu- 
minous constituents  must  only  be  given  sparingly.  The 
yolks  of  eggs  freed  from  the  white,  beaten  up  with  brandy, 
arrowroot  flavoured  with  Madeira,  white  broth,  made  with 
veal  stock,  and  thickened  with  cream  and  arrowroot, 
boiled  sago  or  tapioca,  with  a  httle  milk  added,  furnish  a 
diet  containing  a  maximum  of  starchy  with  a  minimum  of 
nitrogenous  elements. 

With  regard  to  prophylatic  measures,  patients  with 
chronic  disease  of  the  lower  urinary  passages,  should 
ascertain  for  themselves  the  character  of  the  reaction 
of  their  urine,  and  should  be  taught  to  regard  the  per- 
sistence of  an  ammoniacal  condition  as  highly  dangerous. 
They  cannot  be  too  highly  impressed  with  the  importance 
of  thoroughly  carbolizing  all  instruments  they  may  employ 
for  the  relief  of  retention  or  incontinence  of  urine.  And 
never  under  any  circumstances  subject  themselves  to  en- 

u2 


292  DISEASES    OF    THE    KIDXEY. 

forced  retention,  but  always  be  provided  when  on  long 
journeys,  or  attending  public  meetings,  etc.,  with  a  com- 
modious india-rubber  urinal.  The  patient  also  should  be 
careful  about  exposing  himseK  to  damp  and  cold. 


Class  III.     Peei-Nephkitis. 

85.  Symptoms. — The  term  peri-nephritis  is  apphed  to 
the  indammation  of  the  loose  connective  and  adipose  tis- 
sue surrounding  the  kidney.  It  usually  occurs  on  one 
side  only,  but  in  rare  instances  it  may  be  bi-lateral.  The 
kidneys  themselves  may  or  may  not  be  involved  in  the 
inflammatory  process,  but  when  they  are,  the  disease  will 
generally  be  found  to  have  originated  in  them.  The 
cellulo-adipose  tissue  which  surrounds  the  kidney  is  con- 
tinuous with  the  layers  of  cellular  tissue,  which  connect 
aU  the  organs  in  the  neighbourhood  of  the  kidneys  together, 
but  the  most  intimate  connection  subsists  between  it  and 
the  upper  portion  of  the  cellular  tissue  of  the  iliac  fascia, 
and  the  cellular  tissue  of  the  lumbar  region  beyond  the 
quadrati  lumborum,  and  between  the  margins  of  the 
latissimus  dorsi  and  external  oblique  muscles.  These 
connections  must  be  borne  in  mind  when  considering  the 
direction  peri-neiDhritic  abscess  is  Ukely  to  take. 

The  disease  often  commences  insidiously.  At  first  only 
pain,  is  experienced  in  the  lumbar  region,  and  is  often 
mistaken  for  cohc  arising  from  renal  calculus  or  gravel. 
Examination  of  the  urine,  however,  unless  the  kidney  is 
previously  diseased,  shows  nothing  abnormal.  The  pain 
too,  is  usually  more  deep  seated  than  that  which  attends 
renal  cohc,  and  is  rather  of  a  dull  pricking  character,  than 
tearing  and  crushing.  A  marked  rigor  followed  by  sweat- 
ing is  often  an  initial  symptom,  but  may  not  be  noticed 


PEKI- NEPHRITIS.  293 

till  pain  has  been  complained  of  some  two  or  three  days. 
When  once  noticed  the  rigor  recurs  at  least  once  a  day, 
usually  in  the  evening  when  the  temperature  rises  to  102-3" 
F.,  becoming  nearly  normal  towards  morning.  Vomiting 
may  be  an  early  symptom.  The  bowels  are  constipated. 
In  this  stage,  the  disease,  when  on  the  right  side,  has  been 
taken  for  enteric  fever  in  the  first  week,  and  for  peri- typhlitis. 
The  severity  and  seat  of  the  pain  will  distinguish  it  from 
the  early  stage  of  typhoid,  whilst  the  pain  and  swelling  in 
peri- typhlitis  is  more  anterior,  and  situated  lower  down 
than  in  peri- nephritis.  The  swelling  in  the  lumbar  region 
may  develop  slowly,  sometimes  quite  rapidly,  but  at  the 
end  of  a  week,  however,  in  the  generality  'of  cases,  firm 
pressure  with  the  hand  in  the  lumbar  region  elicits  a  feel- 
ing of  resistance,  and  then  if  the  other  hand  is  ^placed 
firmly  on  the  abdomen,  and  a  slightly  swaying  move- 
ment made  with  both  hands,  a  mass  can  often  be  made 
out.  This  may  be  taken  for  a  collection  of  faeces  in 
either  the  ascending  or  descending  colon,  or  if  on  the 
right  side  for  tumour  of  the  liver ;  from  the  first  it  can 
be  distinguished  by  no  diminution  occurring  on  com- 
plete evacuation  of  the  bowels,  and  from  gthe  latter  by 
the  tumour  not  being  affected  by  the  ordinary  respira- 
tory movements,  and  by  being  covered  by  the  colon. 
The  tumour  may  increase  slowly  or  rapidly.  About  this 
time  an  oedema  accompanied  by  a  slight  redness  of  the 
skin  usually  occurs  in  the  lumbar  region,  and  extends  to 
the  hips.  The  thigh  also  becomes  more  or  less  flexed 
upon  the  abdomen  from  pressure  on  the  psoas  muscle. 
When  suppuration  commences  there  is  an  exacerbation  of 
all  the  symptoms.  The  pyrexia  is  more  continuous,  and 
of  a  higher  grade,  and  though  there  are  still  remissions  in 
the  morning  temperature,  they  are  not  so  marked.  The 
swelling  now  rapidly  increases,  and  if  the  pus  is  not  evac- 


294  DISEASES    OF    THE   KIDNEY. 

uated,  it  ■will  endeavour  to  find  a  passage  towards  the  sur- 
face by  burrowing  in  the  neighbouring  layers  of  ceUular 
tissue.  Thus,  it  may  invade  the  ceUular  tissue  of  the 
lumbar  region,  and  point  in  the  situation  that  surgeons 
have  shown  to  be  the  position  where  lumbar  hernia  make 
their  appearance,  viz.,  between  the  margins  of  the  latissi- 
mus  dorsi  and  external  oblique  muscles.  Here  it  may  be 
locaHsed  as  an  abscess,  or  it  may  spread  subcutaneously  over 
the  back  and  hip.  Or  the  matter  may  find  its  way  down- 
wards, passing  from  the  renal  region  to  the  cavity  of  the 
pelvis,  from  thence  it  may  pass  below  Poupart's  ligament 
and  present  in  Scarpa's  triangle,  or  even  discharge  into  the 
hip-joint,  or  it  may  open  into  the  bladder,  the  vagina  or 
intestines.  More  rarely  the  direction  taken  is  upwards, 
and  the  diaphragmatic  cellular  tissue  becomes  involved, 
so  that  pleurisy  and  pneumonia  are  developed,  or  the  ab- 
scess may  even  burst  into  the  bronchial  tubes.  Very 
rarely  indeed,  the  abscess  opens  directly  into  the  peri- 
toneum. The  reason  why  this  event  is  so  uncommon, 
though  it  might  at  first  sight  be  naturally  expected,  is 
as  Trousseau  has  explained,  in  consequence  of  peri- 
nephritic  abscess  being  generally  situated  behind  the  kid- 
ney, where  that  organ  separates  it  from  the  peritoneum ; 
moreover,  when  the  inflammation  does  approach  the  peri- 
toneum, peritonitis  is  induced,  but  the  resistance  caused  by 
the  false  membranes,  serves  to  turn  the  pus  in  another  direc- 
tion. Of  all  possible  events,  pointing  of  the  abscess  in  the 
lumbar  region  is,  in  the  case  of  adults,  by  far  the  most  fre- 
quent; in  children,  however,  the  direction  of  the  abscess  is 
quite  as  frequently  downwards,  either  forming  in  Scarpa's 
triangle,  or  passing  even  into  the  cavity  of  the  hip-joint. 
"When  the  pus  takes  this  du^ection,  the  pecuHar  flexion  of 
the  thigh. on  the  abdomen,  which  is  more  or  less  observ- 
able in  most  cases  as  soon  as  the  tumour  is  of  any  magni- 


PERI-NEPHEITIS.  295 

tude,  becomes  more  marked,  and  even  partial  extension 
becomes  an  impossibility.  The  urine,  except  in  those  rare 
cases  when  the  inflammation  extends  to  the  substance  of 
the  kidney,  or  the  tumour  compresses  the  renal  veins,  is 
not  albuminous. 

86.  Causes. — The  disease  is  frequently  attributed  to 
exposure  to  cold  when  the  body  is  in  a  heated  condition. 
Though  this  may  be  a  potent  exciting  factor,  still  it  may 
be  doubted  if  in  itself  it  is  sufficient  to  cause  the  disease, 
unless  there  be  some  predisposing  cause,  as  for  instance 
some  constitutional  taint,  or  injury,  recent  or  remote,  to 
the  lumbar  region.  Strains  and  blows  across  the  loins 
often  give  rise  to  it,  and  it  may  result  from  incised  wounds 
in  the  renal  region,  though  less  frequently  than  from  con- 
tusion. But  in  the  majority  of  instances  peri-nephritis 
is  secondary  to  disease  of  other  organs  and  tissues.  Thus, 
(a)  it  is  not  uncommon  in  calculous  pyelitis  for  peri-neph- 
ritis to  develop  and  for  the  calculus  to  be  discharged  by 
lumbar  abscess  ;  (6)  as  an  extension  of  inflammation 
of  the  pelvic  cellular  tissue  upward,  as  following  upon 
wounds  of  the  lower  part  of  the  uterus  and  vagina,  or 
after  child-birth,  and  after  operations  on  the  testicle  or 
spermatic  cord  or  rectum ;  (c)  sometimes,  but  this  is  a 
comparatively  rare  event,  a  psoas  abscess  bursts  into  the 
renal  cellular  tissue,  and  thus  gives  rise  to  peri-nephritis  ; 
(d)  or  inflammation  of  the  renal  cellular  tissue  of  pyemic 
character  may  develop  in  enteric  fever,  typhus,  small-pox 
and  scarlet  fever,  in  these  cases  it  usually  happens  that 
the  peri-nephritis  is  on  both  sides.  Trousseau  would  attri- 
bute simply  to  pain  in  the  urinary  organs,  a  large  share 
in  the  causation  of  some  of  these  abscesses,  this  however 
is  doubtful.  It  is  generally  stated  that  peri-nephritis  is 
more  frequent  in  men  than  in  women,  whilst  some  German 
writers  assert  it  to  be  extremely  rare  in  children.    My  own 


296  DISEASES    OF    THE    KIDNEY. 

experience  gathered  from  Hospital  practice,  is  that  cases 
of  peri-nephritis  are  more  frequent  among  women,  conse- 
quent on  the  puerperal  state,  then  in  delicate  ill-nourished 
and  strumous  children,  and  least  of  all  among  men.  The 
reason  why  peri-nephritis  has  heen  considered  to  be  of 
rare  occurrence  with  children  is  that  it  is  often  overlooked 
in  the  earlier  stage,  whilst  later,  owing  to  the  abscess 
taking  a  downward  direction  and  presenting  in  Scarpa's 
triangle,  or  else  actually  bursting  in  the  hip-joint,  it  is 
mistaken  for  psoas  abscess,  or  disease  of  the  hip. 

87.  Diagnosis. — In  the  early  stage  when  the  inflam- 
mation is  on  the  right  side,  the  disease  may  be  mistaken 
for  enteric  fever  in  the  first  or  second  week,  or  for  peri. 
typhlitis.  It  may  be  distinguished  from  these  by  the  seat 
and  severity,  of  the  pain,  by  the  absence  of  gurgling  in  the 
ihac  fossa  ;  by  the  swelling,  if  it  can  be  detected,  being  in 
the  lumbar  region.  When  a  tumour  is  formed  we  have  to 
diagnose  peri-nephritis  from  those  diseases  which  cause 
renal  enlargement,  cancer  of  the  kidney,  hydro-nephrosis, 
hydatids,  pyelitis  and  pyo -nephrosis.  In  the  first  three, 
the  disease  is  chronic  and  unaccompanied  by  pyrexia, 
whilst  in  cancer  there  is  usually  hagmaturia  ;  in  hydro- 
nephrosis there  is  often  an  intermittent  discharge  of 
watery  urine  ;  and  in  the  case  of  hydatids,  booklets 
may  be  passed  per  urethram,  and  oftentimes  the  hydatid 
fremitus  can  be  produced  on  percussion.  In  pyelitis 
and  pyo-nephrosis  the  purulent  condition  of  the  urine 
usually  aflfords  sufficient  indication,  since  the  urine 
in  peri-nephritis  is  clear,  unless  it  is  associated  with 
kidney  disease  ;  but  here  the  fact  that  the  urine  was 
previously  purulent  or  albuminous,  enables  us  to  attri- 
bute to  the  right  cause  the  increase  of  swelling,  pain 
and  fever,  that  occurs  when  the  cellular  tissue  becomes 
involved.     Psoas  abscess  may  be  distinguished  by  the  fact 


PERI-NEPHEITIS. 


297 


that  in  that  disease  forcible  flexion  of  the  ahready  flexed 
thigh,  gives  great  pain,  and  Uttle  is  given  by  firm  pres- 
sure over  the  lumbar  region,  whilst  in  peri -nephritis  the 
reverse  obtains. 

88.  Prognosis. — Idiopathic  peri-nephritis  under  prompt 
treatment  may  subside  in  the  course  of  a  few  days,  other- 
wise it  proceeds  to  suppuration.  This  commences  from 
the  end  of  the  first  to  the  end  of  the  second  week,  dis- 
tinct fluctuation  rarely  occurring  till  the  end  of  the  third 
week.  When  the  abscess  is  opened  early,  and  the  disease 
is  uncomplicated,  the  result  is  usually  favourable.  In 
peri-nephritis  secondary  to  calculous  disease,  the  results 
are  not  quite  so  satisfactory  ;  still  since  surgeons  have  paid 
more  attention  to  the  surgical  diseases  of  the  kidney,  and 
operations  are  undertaken  earlier  than  formerly,  the  num- 
ber of  recoveries  have  greatly  increased.  The  least  favour- 
able results  follow  the  treatment  of  peri-nephritis  when  it 
follows  on  the  puerperal  state  or  in  septic  conditions.  But 
even  in  these  cases  when  the  disease  is  recognised  early 
the  proportion  of  recoveries  is  more  considerable  than  the 
statement  of  some  authors  would  lead  us  to  suspect. 
Even  in  neglected  cases,  where  the  abscess  has  been  per- 
mitted to  burst  into  the  bowels,  or  into  the  lungs,  cases  of 
recovery  are  recorded.  In  forming  an  opinion  in  any 
given  case,  we  must  be  guided  more  by  the  constitutional 
powers  of  the  patient,  than  the  extent  of  the  disease. 
And  our  success  in  treatment  will  be,  in  a  given  number  of 
cases,  directly  proportionate  to  the  early  application  of 
remedial  measures,  and  the  immediate  evacuation  of  the 
abscess  the  moment  fluctuation  is  perceptible. 

89.  Morbid  Anatomy. — The  waUs  of  the  abscess  are 
sometimes  ragged,  sometimes  smooth,  the  latter  conditions 
being  generally  observed  in  cases  of  long-continuance.  Its 
shape  is  irregular,  especially  if  there  has  been  a  tendency  to 


298  DISEASES    OF    THE    KIDNEY. 

burrow.  The  pus  in  idiopathic  cases  is  yellowish  and 
creamy,  but  in  septic  conditions  is  thin  and  of  a  greyish- 
yellow  colour.  The  kidney  in  some  cases  seems  to  have 
been  little  affected  by  the  contiguous  inflammation,  but  in 
most  there  is  evidence  of  some  compression  of  its  substance. 
Karely,  minute  abscesses  are  observed  on  the  surface  of 
the  kidney,  beneath  the  capsule ;  sometimes  it  is  some- 
what softened.  If  the  disease  has  been  of  long- continuance, 
especially  in  septic  cases,  cloudy  swelling  is  observed. 
Otherwise  except  in  those  cases  were  pyelitis  or  pyo- 
nephrosis primarily  existed,  the  organ  has .  sustained  no 
serious  mischief.  When  the  abscess  has  opened  internally 
its  course  can  be  readily  traced. 

90.  Treatment. — In  the  earlier  stages  absolute  rest 
in  bed.  If  the  patient  is  robust,  and  the  disease  idio- 
pathic or  the  result  of  direct  injury,  leeches  should  be 
freely  applied  to  the  affected  side,  and  an  antimonial 
saline,  with  a  sufficient  dose  of  opium  to  relieve  pain, 
given  from  time  to  time.  As  the  bowels  are  generally  ob- 
stinately constipated,  and  as  this  condition  adds  to  the 
discomfort  of  the  patient,  and  the  pressure  of  a  loaded 
colon  on  the  kidney  increases  the  pain,  they  should  be 
promptly  relieved.  For  this  purpose  a  full  dose  of  calo- 
mel followed  a  few  hours  after  by  a  small  dose  of 
Epsom  salts  has  the  most  decided  effect.  By  thoroughly 
clearing  the  bowels  at  first,  the  patient  need  not  be 
troubled  again  for  a  day  or  so,  an  important  consider- 
ation, whilst  a  sharp  purge  has  almost  the  effect  of 
venesection.  These  measures  applied  early  may  lead 
to  resolution  of  the  inflammation.  In  delicate  persons, 
as  in  females  in  whom  the  disease  has  supervened  after 
parturition,  or  in  ill-nourished  strumous  children,  or  when 
the  disease  occurs  in  the  course  of  small-pox,  scarlet  fever, 
typhus,  etc.,  the   treatment  must  be  less  active.      Pain 


PERI-NEPHRITIS.  ^^^ 


must  be  relieved  by  opium,  and  the  best  form  of  administer- 
ing it  is  as  Dover's  powder,  whilst  the  bowels  must  be 
opened  by  means  of  castor  oil.     Inunctions  of  belladonna 
to  the  affected  side  prove  very  serviceable  and  afford  con- 
siderable relief.     These  cases  rarely  if  ever  terminate  m 
resolution.     When  the  pyrexia  becomes  more  continuous, 
and  the  rigors  more  marked,  indicating  that  suppuration 
has  commenced,  and  if  a  definite  sweUing  can  be  made  out, 
puncture  and  the  withdrawal  by  means  of  the  aspu:ator 
of  some  of  the  contents  wHl  afford  considerable  relief,  even 
if  no  pus  be  met  with.     At  the  same  time  large  poultices 
should  be  frequently  appUed.      As  soon  as  fluctuation  is 
perceptible  the  surgeon  should  be  requested  to  evacuate 
the  pus  by  means  of  a  free  incision.      The  necessity  of 
calling  in  surgical  assistance  early  cannot  be  too  emphati- 
caUy  insisted  on ;    a  few  hours  delay  may  lead  to  formid- 
able burrowing  of  pus,  and  an  extensive  destruction  of  the 
soft  tissues. 


Class  IV.     Specific  Conditions. 

The  instances  in  which  suppurative  inflammation  is  ex- 
cited in  the  kidney  by  specific  causes,  as  for  instance,  in 
tubercular  disease  of  that  organ,  will  be  referred  to  m  a 
subsequent  chapter,  and  require  no  special  mention  m 
this  place.     (See  Scrofulous  Infiltration  of  the  Kidney). 


800  DISEASES    OF    THE    KIDNEY. 

CHAPTEE   V. 
Degenerations     and     Infiltrations      of     the      Ejdney. 

Lardaceous  Degeneration. 

91.  Etiology. — Waxy  or  lardaceous  degeneration  of 
tlie  kidney  was  formerly  considered  to  be  a  stage  of 
Bright' s  disease,  indeed  even  at  the  present  day  when  the 
exact  nature  of  the  process  is  fully  understood,  many 
writers  on  Bright' s  disease  still  include  it  in  their  classifi- 
cation. Lardaceous  degeneration,  however,  is  a  process 
quite  independent  of  nephritis,  although  the  two  conditions 
are  often  associated  together.  Thus  a  waxy  kidney  may 
become  the  seat  of  nephritis,  or  lardaceous  degeneration 
develop  in  a  granular  kidney.  Lardaceous  degeneration 
when  it  occurs  is  hardly  ever  limited  to  the  kidney  but 
affects  other  organs  as  well,  especially  the  liver,  spleen  and 
intestines,  indeed  the  kidney  is  generally  the  organ  least 
affected.  According  to  statistics  collected  by  Dr.  Chaii- 
wood  Turner  (Path.  Soc.  Trans.,  1879),  the  spleen  was 
affected  48  times,  the  liver  30  times,  the  kidneys  15  times, 
and  the  intestines  10  times  out  of  58  cases.  Waxy 
degeneration  of  the  kidney  therefore  must  be  regarded 
as  a  general  affection  of  the  system. 

Lardaceous  degeneration  is  usually  secondary  to  long- 
standing suppurative  disease,  whilst  it  is  also  frequently 
associated  with  constitutional  syphilis,  scrofula,  or  cancer. 
Dr.  Charlwood  Turner  out  of  58  cases  collected  by  him, 
found  that  43  occurred  in  association  with  prolonged  sup- 
puration. These  included  20  cases  of  phthisis,  13  cases 
of  bone  disease  of  which  six  were  due  to  caries,  four  to 
necrosis  and  three  to  disease  of  the  joints.     Of  the  re- 


LAEDACEOUS    DEGENERATION.  301 

maining  15  cases,  8  were  found  in  association  with  syphilis, 
six  with  mahguant  disease,  and  one  in  a  patient  suffering 
from  the  hemorrhagic  diathesis.  In  one  of  the  cases  as- 
sociated with  syphilis,  and  two  of  the  cases  associated 
with  maHgnant  disease,  there  was  a  history  of  ague.  The 
connection  between  ague  and  waxy  degeneration  has  been 
disputed,  but  Sir  Joseph  Fayrer  has  recorded  as  the  re- 
sult of  his  experience  that  apart  from  the  long-continued 
suppuration  of  dysentery,  waxy  degeneration  is  an  occa- 
sional result  of  tropical  malarious  disease.  I  have  re- 
corded {Path.  Soc.  Trans.,  1879,  p.  537)  an  instance, 
confirming  this  statement,  in  an  old  Greenwich  pensioner, 
aged  90,  who  died  apparently  from  old  age,  but  whose  liver 
and  spleen  were  enormously  enlarged  from  infiltration  of 
lardaceous  matter.  All  his  other  organs  were  sound, 
there  was  no  evidence  of  old  abscesses  or  other  cause  of 
suppuration,  nor  of  any  dysenteric  attack,  nor  of  syphilis, 
but  he  had  been  much  exposed  to  malaria  in  the  West 
Indies.  In  chronic  Bright's  disease,  the  long- continued 
drain  of  albumin  is  supposed  to  be  the  main  cause 
of  the  infiltration  of  lardaceous  material  that  so  fre- 
quently occurs.  Whilst  ua  phthisis,  chronic  nephritis 
follows  on  previous  waxy  infiltration,  the  result  of  the 
chronic  suppuration  from  pulmonary  cavities.  Larda- 
ceous degeneration,  in  some  rare  instances,  may  be 
quite  localized,  depending  on  a  long- continued  suppura- 
tion limited  to  the  affected  organ,  an  instance  of  this  is 
occasionally  seen,  when  one  kidney,  which  has  been  the 
seat  of  calculous  pyelitis  is  found  after  death  to  be  infil- 
trated with  waxy  material.  Neither  age  nor  sex  have  any 
special  bearing  on  the  etiology  of  the  disease,  given  long- 
continued  suppuration,  or  the  constitutional  cachexia  of 
struma,  syphilis  or  cancer,  lardaceous  changes  follow 
independently  of  age  or  sex. 


302  DISEASES    OF    THE    KIDNEY. 

92.  Symptoms. — When  in  the  course  of  an  exhaust- 
ing disease,  connected  with  prolonged  suppuration  or 
syphilitic  or  other  cachexise,  we  find  the  urine  becoming 
profuse,  of  low  specific  gravity,  of  nearly  neutral  reaction, 
and  containing  a  small  quantity  of  albumin,  and  deposit- 
ing a  fine  white  deposit,  which  on  examination  is  found  to 
consist  of  lymph  corpuscles,  a  few  fatty  epithelial  cells 
and  fine  hyaline  casts,  whilst  with  these  symptoms  there 
is  no  hypertrophy  of  the  heart,  we  may  conclude  that  the 
Mdney  has  become  the  seat  of  lardaceous  infiltration.  In 
uncomplicated  cases  this  character  of  the  urine  is  main- 
tained throughout,  only  the  albumin  frequently  becomes 
more  abundant  as  the  case  progresses,  though  the  amount 
passed  on  successive  days  is  extremely  variable.  The 
paraglobulin  often  exceeds  the  serum  albumin.  The  casts, 
too,  in  long-standing  cases,  may  stain  with  iodine  ;  this, 
however,  is  not  always  observed.  If  the  case  become 
complicated  with  acute  nephritis,  the  urine  becomes  scanty, 
and  dropsy  may  ensue ;  if  on  the  other  hand  chronic 
nephritis  supervene,  cardio-vascular  changes  will  be  ob- 
served, though  owing  to  the  debility  of  the  patients  they 
never  attain  a  prominence  as  marked  as  in  uncomplicated 
interstitial  nephritis.  Though  general  dropsy  is  not  a 
symptom  of  uncomplicated  lardaceous  infiltration,  still  a 
little  puffiness  round  the  ankles,  especially  in  the  later 
stages  of  the  disease,  will  frequently  make  its  appearance, 
this  no  doubt  is  owing  to  the  hydremic  condition  of  the 
blood  that  is  so  marked  in  these  cases.  As  the  liver  and 
spleen  are  nearly  always  affected  as  well,  any  enlargement 
of  these  organs  will  aid  our  diagnosis,  though  it  must  not 
be  forgotten  that  both  may  be  the  seat  of  extensive  in- 
filtration without  their  being  perceptibly  increased  in 
volume;  when,  however,  the  liver  and  spleen  are  infil- 
trated to  a  considerable  extent,  abdominal  dropsy  (ascites) 


LARDACEOUS    DEGENEBATION.  303 

makes  its  appearance.  The  appetite  is  rarely  affected, 
often  the  patients  crave  for  food,  and  digest  with  comfort, 
though  if  the  intestines  be  also  affected  they  are  troubled 
with  diarrhoea,  and  as  this  is  apt  to  follow  on  the  inges- 
tion of  food,  it  is  advisable  to  give  it  in  as  nutritious  and 
easily  digestible  form  as  possible.  Owing  to  the  debili- 
tated condition  of  the  patients,  they  are  extremely  Hable 
to  secondary  inflammation,  especially  of  the  serous  mem- 
branes, and  they  are  also  extremely  liable  to  thrombosis. 
Patients  suffering  from  lardaceous  degeneration  of  the 
kidneys  become  rapidly  pale,  and  complain  of  fatigue  on 
the  slightest  exertion. 

93.  Prognosis. — The  duration  of  the  disease  in  its 
various  stages  is  very  variable,  depending  in  great  mea- 
sure on  the  individuality  of  the  patient,  the  circum- 
stances in  which  he  is  placed,  on  the  development  of 
the  disease,  and  the  secondary  complications  that  it  may 
give  rise  to.  Dr.  Goodhart  (Path,  8oc.  Trans.,  1879, 
p.  585)  has  made  some  observations  as  to  the  length  of 
time  that  must  elapse  between  the  commencement  of 
suppuration  and  the  production  of  the  disease.  Accord- 
ing to  his  experience  at  Guy's  it  appears  that  three 
months  is  the  shortest  period  in  which  the  disease  is 
known  to  have  occurred,  and  also  that  the  duration  of  the 
suppuration  necessary  to  produce  lardaceous  disease 
depends  in  great  measure  upon  the  duration  and  inten- 
sity of  the  fever.  If  either  in  suppuration,  or  syphilis,  the 
pyrexia  be  great  or  perhaps  prolonged  without  much  in- 
tensity, other  things  being  not  adverse,  the  lardaceous 
change  will  be  produced  rapidly.  In  hot  climates  not 
only  is  the  disease  very  rife  but  its  progress  is  also  rapid. 
Death,  however,  as  the  result  of  mere  lardaceous  degene- 
ration of  the  kidney  is  rare,  the  event  being  due  to 
either  the  exhaustion  caused  by  the  original  disease,  or 


304  DISEASES    OF    THE    KIDNEY. 

to  the  general  extension  of  the  infiltration  to  other  organs 
leading  to  marasmus  from  impairment  of  nutrition,  or 
from  secondary  inflammations  or  thrombosis.  On  the 
other  hand  in  cases  where  the  originating  disease  is  re- 
movable, as  in  caries  or  necrosis  of  bone,  the  health 
of  the  patient  is  often  materially  improved  for  a  time  by 
the  relief  of  these  conditions.  Whether  a  cure  is  ever 
possible  is  still  a  disputed  point.  Dr.  Dickinson  {Path. 
Soc.  Trans.,  1879)  relates  a  case  following  on  constitutional 
syphilis  in  which  a  cure  seemed  certainly  to  have  been 
effected.  He  also  relates  a  case  which  lived  for  eight 
years  after  the  first  appearance  of  the  disease,  the  greater 
part  of  which  was  passed  in  apparent  good  health. 

94.  Diagnosis. — In  lardaceous  disease  we  have  to 
distinguish  between  it  and  other  conditions  leading  to 
albuminuria.  It  is  most  Ukely  to  be  taken  for  granular 
contracted  kidney,  in  both  we  have  a  profuse  flow,  low 
specific  gravity,  and  only  a  small  amount  of  albumin.  In 
contracted  kidney,  however,  the  polyuria  is  more  marked, 
and  the  specific  gravity  is  often  much  lower,  (in  waxy 
kidney  Bartels  says  it  probably  never  falls  below  1*006) 
the  urea  is  more  reduced  than  is  the  case  in  lardaceous 
degeneration  of  the  kidneys,  whilst  in  the  latter  instance 
there  are  no  cardio-vascular  changes,  and  ursemic  con- 
vulsions are  very  rare.  It  is  distinguished  from  tubal 
nephritis  by  the  difference  in  the  character  of  the  urine, 
and  absence  of  general  dropsy  ;  the  oedema  of  waxy  dis- 
ease of  the  kidneys,  unless  associated  with  nephritis,  being 
confined  to  the  abdomen  and  lower  extremities.  In  waxy 
degeneration  of  the  kidney,  the  urine  does  not  become 
scanty  and  high  coloured,  unless  there  is  some  febrile 
complication,  whilst  in  tubal  nephritis  that  is  the  ordinary 
condition  of  the  secretion.  The  supervention  of  tubal 
nephritis  on  waxy  degeneration  is  consequently  marked 
by  the  transition  from  an  abundant  discharge  of  urine  of 


LARDACEOUS    DEGENEEATION.  305 

low  specific  gravity  to  a  scanty  discharge  of  high  coloured 
urine  of  high  specific  gravity.  The  albuminuria  of 
pyrexia  can  generally  be  distinguished  from  that  of 
waxy  infiltration  by  its  dependence  on  the  course  of  the 
temperature,  by  the  previous  history  of  the  case,  but  in 
cases  of  hectic  dependent  on  phthisis,  or  long-continued 
suppuration,  the  differentiation  between  the  two  often  be- 
comes exceedingly  difficult.  On  the  other  hand  the  albu- 
minuria from  extra  renal  sources  can  usually  be  readily 
made  out,  by  reference  to  the  morbid  conditions  existing 
in  the  urinary  passages.  The  diagnosis  between  func- 
tional albuminuria  and  that  due  to  waxy  infiltration,  as  a 
rule,  is  not  difficult.  In  the  former  there  is  generally  no 
very  marked  increase  of  the  urine  secreted,  the  specific 
gravity  is  rarely  lowered,  indeed  is  often  more  than  nor- 
mal, the  urea  is  generally  in  excess,  whilst  there  is  an 
absence  of  that  remarkable  pallor  and  emaciation  so 
characteristic  of  the  victims  to  lardaceous  degeneration. 
In  all  cases  our  diagnosis  will  be  aided  by  a  careful  con- 
sideration of  the  etiological  details  of  the  ease. 

95.  Morbid  Anatomy. — Lardaceous  infiltration  usu- 
ally affects  both  kidneys  and  generally  equally.  De- 
generation of  one  kidney  is  exceptional,  though  it  may  be 
observed  if  the  organ  has  been  the  seat  of  long  continued 
suppuration  from  calculous  pyelitis,  or  of  cancer.  The 
affected  kidneys  in  the  early  stage  are  only  slightly,  if  at 
all  enlarged,  in  appearance  they  may  be  slightly  paler  than 
usual,  whilst  on  section  the  glomeruli  may  appear  pro- 
minent and  sparkling.  No  apparent  change,  however, 
may  be  noticed,  till  the  cut  surface  is  washed  with  iodine 
or  methyl  aniline  violet,  when  the  degenerated  glomeruli 
acquire  a  stain  from  these  reagents,  and  stand  out  like 
spotted  points.  As  the  disease  advances,  and  the  waxy 
infiltration  affects  other  vessels  of  the  kidney  besides  the 


306  DISEASES    OF    THE    KIDNEY. 

glomeruli,  and  the  vasa  afferentia,  sucli  as  the  vasa  recta, 
vasa  efferentia,  and  the  inter-lobular  vessels,  an  increase 
in  the  size  of  the  kidney  takes  place,  which  may  he  very 
considerable.  The  surface  of  the  organ  is  smooth  and 
the  capsule  readily  removed.  The  enlargement  is  most 
marked  in  the  cortex,  which  is  of  a  pale  yellow  colour,  and 
contains  hut  little  blood,  whilst  the  pyramids  are  usually 
red,  it  being  only  in  an  advanced  stage  of  the  disease  that 
the  pyramidal  portion  of  the  kidney  becomes  involved  and 
the  cut  section  of  the  kidney  assumes  an  homogeneous 
aspect.  The  Malpighian  tufts  stand  out  from  the  trans- 
lucent wax-like  surface,  like  glistening  points,  "  dew- 
drops,"  as  Meckel  has  poetically  described  them.  If  the 
surface  be  now  washed  with  iodine  or  methyl  violet,  it 
will  be  seen  how  extensive  is  the  infiltration,  all  the 
vessels  exposed  to  the  action  of  the  reagent  acquiring  a 
stain,  and  bringing  them  out  as  prominently  as  if  injected. 
A  third  or  final  stage  of  waxy  kidney  has  been  described, 
but  it  is  evidently  due  to  the  association  of  other  pro- 
cesses such  as  tubal  or  interstitial  nephritis.  In  these 
kidneys,  the  homogeneous  wax-like  appearance  of  the 
cortex  is  often  streaked  with  a  number  of  minute  yellow- 
ish white  hnes,  the  result  of  the  fatty  changes  in  the 
epithelium  of  the  tubules.  The  superficial  cortex  is 
diminished  in  volume,  the  capsule  is  more  or  less  ad- 
herent to  the  surface  of  the  organ,  and  becomes  marked 
with  irregular  depressions.  If  in  addition  to  this  diminu- 
tion of  bulk  from  atroxDhic  changes  in  the  tubules,  there 
has  also  been  an  increase  of  the  inter-tubular  connective 
tissue,  the  shrinking  will  be  more  considerable.  In  these 
kidneys  the  staining  with  iodine  and  methyl  violet  often 
takes  place  in  a  very  irregular  manner,  little  or  none  tak- 
ing place  in  the  cortex,  whilst  the  papillae  stain  deeply, 
stained  lines  running  up  from  the  apex  into  the  pyramid. 


LARDACEOUS    DEGENEEATION. 


307 


The  staining  of  this  part  of  the  kidney,  which  is  not 
noticed  during  the  earher  period  of  waxy  infiltration,  is 
probably  accounted  for  by  the  fact  that  the  hyaline  walls 
of  the  tubules  have  become  affected,  whilst  the  disappear- 
ance of  the  staining  in  the  cortical  portion  may  be  ex- 
plained by  the  breaking  up  of  the  waxy  matters  by  fatty 
degeneration.  In  connection  with  this  latter  circum- 
stance Dr,  Moxon  {Path.  Sue.  Trans.,  1879)  has  re- 
marked that  under  typhoid  fever  he  has  known  lardace- 
ous  organs  recover  themselves ;  it  may  be  that  pyrexia,  as 
well  as  local  inflammation,  leads  to  molecular  degenera- 
tion of  the  infiltrated  material,  and  thus  facihtates  its  ab- 
sorption and  removal. 

The  deposit  of  waxy  material  commences  in  the  Mal- 
pighian   bodies,    and   then   affects    the    afferent   arteries, 


Fig.  29. — Lardaceous  degeneration  of  the  Malpigliian  tuft  and  small 
arteries  (Green's  Pathology). 


(fig.  29).  The  vasa  recta  are  next  involved,  the  vasa 
efferentia  and  the  inter-tubular  vessels  being  usually 
the  last  attacked.  At  a  very  late  stage  of  the  process 
the   urinary  tubules    may  become    involved,   when   this 

x2 


308  DISEASES    OF    THE    KIDNEY. 

is  the  case  it  is  the  hyaline  wall  of  the  lower  part  of 
the  collecting  tubes  of  the  pyramids  that  first  become 
the  seat  of  this  deposit.  The  epithelium  at  an  early 
stage  of  the  disease  is  normal,  but  later  on  it  undergoes 
fatty  changes.  Cysts  are  often  observed,  they  may  be 
caused  either  by  the  irregular  compression  of  the  infil- 
trated material ;  or  as  is  more  frequently  the  case,  from 
the  shrinking  of  the  inter-tubular  connective  tissue  the 
result  of  associated  interstitial  nephritis.  Casts  are  not 
numerous,  when  found  in  the  tubules  they  are  hyaline, 
sometimes  covered  with  fatty  epithelium.  The  majority 
are  simply  the  result  of  exudation,  though  sometimes  they 
seem  to  be  composed  of  lardaceous  material,  and  stain 
with  iodine  and  methyl  violet ;  these,  however,  are  only 
met  with  in  the  later  stages  of  the  disease,  when  the 
tubules  have  become  the  seat  of  the  infiltration. 

Lardacein  may  be  obtained  from  the  tissues  by  Kiihne's 
process.  The  kidney  is  finely  minced  and  extracted  with 
cold  water  and  subsequently  with  dilute  alcohol  till  the 
mass  becomes  colourless,  it  is  then  digested  with  artificial 
gastric  juice  for  several  hours.  The  precipitate,  left  after 
filtration,  consists  almost  entirely  of  pure  lardacein  with 
the  exception  of  a  little  mucin  and  elastic  tissue,  all  the 
other  proteids  being  digested  and  removed  by  the  filtrate. 
After  being  thoroughly  washed  and  dried,  lardacein  has  a 
snowy  white  appearance,  insoluble  in  water,  and  does  not 
swell  in  solution  of  sodium  chloride.  It  is  soluble  in 
dilute  ammonia  from  which  it  can  be  precipitated  by  di- 
lute acids.  With  iodine  it  stains  a  mahogany -brown,  and 
this  reaction  was  supposed  to  be  peculiar  to  it,  but  I  have 
shown  (Path.  Soc.  Trans.,  1879)  that  casein,  syntonin  and 
dried  fibrin  equally  develop  the  reaction,  though  not  co- 
agulated serum  albumin.  Methyl  aniline  violet  stains 
lardacein  a  rosy  red.     A  blue  colour  is  developed  by  the 


LABDACEOUS    DEGENERATION. 


309 


joint  action  of  iodine  and  sulphuric  acid,  but  this  colora- 
tion can  be  caused  by  the  admixture  of  iodine  and  sul- 
phuric acid,  without  the  intervention  of  lardacein,  or  any 
other  substance,  the  blue  colour  being  probably  due  to  the 
volatilization  of  the  iodine  by  the  sulphuric  acid. 

Some  difference  of  opinion  exists,  as  to  the  real  nature 
of  the  deposited  material,  whether  it  is  the  result  of 
chemical  changes  in  the  tissues  themselves,  or  whether 
it  is  a  morbid  material  derived  from  the  blood.  When 
first  discovered  it  was,  from  the  blue  colour  given  with 
iodine  and  sulphuric  acid,  supposed  to  be  allied  to  starch, 
hence  the  term  amyloid  substance  applied  to  it.  Chemical 
analyses,  however,  have  proved  it  to  contain  nitrogen,  and 
by  its  exhibiting  the  xantho-proteic  and  Millon's  reactions 
it  is  shown  to  be  a  proteid  substance.  Its  composition  is 
as  follows  : — carbon  53-6,  hydrogen  7'0,  nitrogen  15-0, 
oxygen  23-1,  sulphur  1-3.  Dr.  Dickinson  regards  it  as 
de-alkaUsed  fibrin,  and  maintains  that  he  has  obtained  it 
artificially  by  digesting  fibrin  in  dilute  hydrochloric  acid, 
he  beUeves  the  de-alkalization  is  caused  by  the  withdrawal 
of  potash  salts  from  the  tissues,  the  result  of  long-con- 
tinued discharge  of  pus.  In  proof  of  this,  he  quotes 
analyses  made  by  Dr.  Dupre,  which  show  that  the  potash 
in  healthy  liver  tissue  is  0*209,  and  in  the  spleen  0-311 
in  100  parts,  whilst  in  lardaceous  degeneration  of  these 
organs  the  potash  is  reduced  to  0-151  and  0-196  respec- 
tively. Dr.  Dickinson  also  considers  the  fact,  that  the 
brown  stain  caused  by  iodine  with  lardacein  is  removable 
by  the  action  of  dilute  solutions  of  potash,  but  is  restored 
by  the  action  of  an  acid,  is  an  additional  proof  that  the 
reaction  with  iodine  is  associated  with  the  condition  of 
acidity  that  is  with  the  removal  oi  alkali.  In  answer  to 
this  view,  it  is  maintained  that  the  action  of  dilute  hydro- 
chloric acid  on  fibrin  can  have  no  otlier  efi"ect  than  to  con- 


310  DISEASES    OF    THE    KIDNEY. 

vert  it  into  syntonin,  and  yet  we  know  that  syntonin  is 
not  lardacein,  since  the  former  is  soluble  in  acids  and 
alkalies,  and  digestible  in  gastric  juice,  which  the  latter  is 
not.  Syntonin  only  resembles  lardacein  by  the  fact  that 
both  give  the  same  coloration  with  iodine,  a  circumstance 
that  has  perhaps  led  Dr.  Dickinson  to  regard  both  pro- 
ducts as  identical.  Again,  as  Dr.  Pye  Smith  (Path.  Soc. 
Trans.,  1879)  has  observed,  the  decolorizing  effect  on  the 
iodine  reaction  is  not  caused  by  its  action  on  lardacein 
but  on  the  iodine,  since  the  same  effect  occurs  when  we  use 
liquor  potasssB  to  efface  stains  of  iodine  on  the  finger,  the 
unstable  coloured  compound  of  iodine  is  decomposed,  and 
potassium  iodide  is  formed,  which  is  in  turn  decomposed, 
and  the  colour  restored  by  the  addition  of  acid.  I  have 
also  shown  {Path.  Soc.  Trans.,  vol.  xxx.)  that  the  iodine 
reaction  does  not  depend  upon  the  withdrawal  of  alkali 
from  the  fibrin,  since  alkali  albumin,  if  all  traces  of 
free  alkali  are  carefully  removed,  made  by  treating  fibrin 
with  liquor  potassse,  developes  the  reaction  as  well  as  acid 
albumin  made  by  treating  fibrin  with  dilute  acid.  Lastly, 
the  deficiency  of  potash  existing  in  the  affected  tissues, 
may  be  accounted  for  by  the  increase  of  fat  in  them,  since 
we  know  that  tissues  that  have  undergone  fatty  degenera- 
tion become  poorer  in  saline  constituents. 

With  regard  to  the  actual  nature  of  the  product  it  is 
impossible  as  yet  to  express  anything  like  a  definite 
opinion,  still  there  are  many  points  which  indicate  that 
lardacein  is  a  mixture  of  a  proteid  with  a  fatty  body, 
of  which  we  have  a  physiological  example  in  vitel- 
lin,  which  Hoppe  Seyler  considers  to  be  an  admixture 
of  globulin  with  lecithin.  However  this  may  be.  Dr. 
Stephen  Mackenzie  in  the  debate  on  lardaceous  disease  at 
the  Pathological  Society,  made  an  important  suggestion, 
in  pointing  out  a  probable  connection  between  hyaline  and 


LAEDACEOXJS    DEGENERATION.  311 

lardaceoiis  degeneration.  For  though  the  hyaline  material 
gives  no  definite  reaction  with  iodine,  still  the  further 
study  of  this  condition  may  throw  considerable  light  upon 
lardaceous  degeneration  being  associated  with  alterations 
in  the  blood,  for  it  might  be  that  the  difference  between 
the  hyaline  and  waxy  is  only  one  of  degree,  the  hyaline 
being  the  first  step  in  the  degenerative  process,  brought 
about  by  pyrexial  conditions,  which,  if  long- continued, 
leads  to  waxy  deposit.  Looked  at  in  this  light,  Dr.  Good- 
hart's  observations  made  at  the  same  debate,  and  to  which 
allusion  has  been  made  in  speaking  of  the  symptoms  of 
the  disease,  with  regard  to  the  relation  between  the  pro- 
duction of  lardaceous  disease  and  the  intensity  of  fever, 
acquire  additional  interest.  In  any  further  inquiry  that 
may  be  undertaken  to  investigate  the  exact  nature  of  this 
product,  and  to  put  its  composition  beyond  doubt,  I  would 
suggest  that  the  nature  of  the  fatty  changes  occurring  in 
the  organs  in  this  disease  should  also  be  considered.  No 
one  can  view  the  pecuUar  translucent  waxy  appearance  of 
the  cut  sections  without  at  once  recognizing  the  fact  that 
the  fatty  matter,  to  which  it  is  undoubtedly  due,  is  present 
in  a  form  unlike  any  other  kind  of  fatty  deposit,  suggest- 
ing the  idea  that  it  is  either  some  peculiar  kind  of  fat,  or 
else  ordinary  fat  mixed  with  some  other  constituent. 

96.  Treatment. — In  all  cases  we  must  enquire  into 
the  originating  conditions  and  endeavour  to  relieve  them. 
If  due  to  suppuration  from  diseased  bone,  means  must  be 
taken  to  check  further  discharge  by  the  removal  of  the 
dead  bone,  etc.  If  from  phthisis,  scrofula,  or  syphilis,  by 
proper  constitutional  remedies.  With  regard  to  the 
treatment  dhected  towards  the  infiltrated  organs,  iodide  of 
potassium  has  often  proved  of  great  service,  especially 
when  dependent  on  constitutional  syphilis.  It  should  be 
given  in  large  doses,  from  15  to  20  grains,  three  times  a 


312 


DISEASES    OF    THE    KIDNEY. 


day.  The  administration  of  cod-liver  oil  at  the  same  time 
improves  the  patient's  general  condition.  In  cases,  how- 
ever, independent  of  syphilis,  I  prefer  the  use  of  iodide  of 
iron,  to  iodide  of  potassium,  and  I  beheve  its  ef&cacy  to 
be  greatly  increased  by  the  addition  of  arsenic  ( J^  grain 
arseniate  of  iron).  In  a  patient  recently  under  my  care 
at  the  London  Hospital  very  great  improvement  followed 
the  combined  administration.  The  hver  and  spleen,  which 
were  considerably  enlarged  when  the  treatment  was  com- 
menced, at  the  end  of  three  months  were  nearly  of  normal 
dimensions,  whilst  the  urine  became  nearly  free  from 
albumin.  Although  a  course  of  mercury  cannot  be  ven- 
tured on,  yet  great  benefit  ensues  from  an  occasional  dose, 
not  only  in  cases  associated  with  syphihs  but  in  others, 
especially  when  the  hver  is  imphcated  and  ascites  is  pre- 
sent. A  grain  of  grey  powder  combined  with  digitalis  and 
squill  may  be  administered,  for  many  nights  following, 
and  its  use  is  attended  by  increased  excretion  of  urea, 
and  often  prodigious  diuresis,  and  rehef  to  the  ascites, 
if  present.  In  those  cases  where  the  intestines  become 
the  seat  of  lardaceous  de^^osit,  and  there  is  considerable 
diarrhoea,  bismuth  proves  most  serviceable. 

Cystic  Degeneration. 

Under  this  head  we  have  to  consider: — 1.  Congenital 
renal  cysts  ;  2.  Renal  cysts  in  adults,  primary  and  secon- 
dary ;  whilst  3.  Hydro-nephrosis  or  the  dilatation  of  the 
pelvis  with  destruction  of  kidney  substance,  is  also  most 
conveniently  studied  in  this  place. 

97.  Congenital    Renal   Cysts Both    kidneys    are 

usually  affected,  and  sometimes  attain  such  a  size  as  to 
impede  delivery.  Then-  usual  size,  however,  ranges  from 
three  to  six  inches  in  length,  and  two  to  four  inches  in 


CYSTIC    DEaENEBATION.  313 

width,  and  weight  from  three  and  a  half  to  five  ounces. 
Their  surface  is  studded  with  numerous  projecting  cysts, 
whilst  on  section  it  is  found  that  nearly  the  whole  of  the 
kidney  structure  has  disappeared,  being  replaced  by  a 
congress  of  cysts  of  different  sizes,  these  being  generally 
filled  with  a  darkish  coloured  fluid,  which  contains  urea, 
and  is  more  or  less  albuminous.  Virchow,  who  was  the 
first  to  thoroughly  investigate  the  nature  of  the  disease, 
showed  that  it  was  caused  by  an  embryonic  inflammation 
of  the  tubules,  which  occluded  the  papilla,  and  he  thought 
that  the  inflammation  originated  from  the  infarcts  of  uric 
acid  and  urates  so  frequently  deposited  in  the  straight 
tubes  during  foetal  life  (see  calculous  disease  of  kidney). 
This,  probably,  is  the  explanation  in  the  majority  of  cases, 
but  in  some  it  is  probable  that  increased  connective  tissue 
formation  plays  a  part  in  the  causation,  whilst  others  may 
be  referred  to  the  metamorphosis  of  the  epithelium,  in 
some  portions  of  the  tubules,  into  colloid  matter  (Forster, 
Pathological  Anatomy,  p.  468).  Dr.  Ewart  has  recorded 
[Pathological  Society's  Transactions,  1880)  a  case  of  cystic 
degeneration  of  the  left  kidney  and  ureter  in  a  new-born 
infant,  in  which  the  obstruction  was  due  to  a  valvular 
fold  of  mucous  membrane  in  the  ureter,  which  allowed  the 
passage  of  a  probe  upwards,  but  not  downwards.  Con- 
genital cystic  degeneration  of  the  kidney  has  also  been 
found  associated  with  hydatids,  an  interesting  case  of 
which  is  recorded  by  Dr.  Cayley  [Pathological  Society's 
Transactions,  1874).  The  subjects  of  congenital  cystic 
disease  have  generally  some  other  congenital  defect, 
clu|)-foot,  webbed  fingers,  transposition  of  viscera,  imper- 
forate anus,  encephalocele,  are  among  the  most  frequent 
examples,  whilst  Ebstein  relates  a  case  in  which  with  cys- 
tic kidney  on  the  right  side,  the  right  lower  extremity  and 
right  half  of    the   female   genitals   were   absent,   whilst 


314  DISEASES    OF    THE    KIDNEY. 

nothing  abnormal  was  found  on  the  left  side  of  the  body. 
Most  of  the  children  with  cystic  disease  are  born  pre- 
matnrely,  and  either  are  still-born,  or  else  die  soon  after- 
wards. In  some  where  the  disease  is  limited  to  one  kidney, 
life  may  be  prolonged,  Mr.  Knowsley  Thornton  and  Dr. 
Day  have  recorded  a  case  of  this  kind,  which  was  believed 
to  be  congenital,  in  which  the  kidney  was  removed,  and 
six  months  afterwards  the  patient  was  reported  to  be 
much  improved  in  health,  and  to  have  grown  considerably 
[Lancet,  June  5th,  1880). 

98.  Cystic  Degeneration  after  Birth.  —  1.  Pri- 
mary cystic  formation  is  most  commonly  observed  during 
middle  life.  Both  kidneys  are  usually  affected,  though  as 
a  rule  to  an  unequal  extent.  It  is  twice  as  frequent  in 
men  than  women  (Ebstein).  The  disease  runs  a  very 
insidious  course,  with  often  a  sudden  termination  in 
ursemic  convulsions.  In  some  cases  a  history  of  a  blow, 
or  a  strain  can  be  obtained,  otherwise  there  is  no  special 
etiological  condition  associated  with  the  disease.  The 
symptoms  are  usually  obscure,  if  there  be  great  enlarge- 
ment of  the  kidney,  a  tumour  will  be  felt  in  the  loins, 
whilst  an  intermittent  hsematuria  and  albuminuria,  and 
the  discharge  of  urine  of  abnormally  low  specific  gravity, 
are  the  most  constant  phenomena  observed,  but  even 
these  may  be  absent,  and  we  may  remain  unaware  of  the 
existence  of  any  renal  mischief  till  after  death.  The  kid- 
ney when  removed  from  the  body  presents  a  remarkable 
lobutated  appearance,  owing  to  the  projection  of  the 
numerous  cysts.  These  vary  in  size  from  minute  points 
up  to  that  of  a  fair  sized  orange,  and  their  colour  may  be 
either  dark  and  purphsh,  reddish-brown,  or  greenish-yel- 
low, so  that  the  whole  appearance  of  the  transformed 
organ  has  the  resemblance  to  a  bunch  of  unequally 
ripened  grapes.     On  section  it  will  be  found  that  the  cysts 


CYSTIC    DEGENERATION.  315 

are  independent  of  each  other,  and  that,  with  the  exception 
of  a  few  that  may  have  been  ruptured,  their  walls  are 
closed.      Their   contents   are   usually  limpid,   sometimes 
gelatinous ;  whilst  serum  albumin,  altered  blood,  crystals 
of  cholesterine,  and  oxalate  of  lime,  are  the  chief  consti- 
tuents, true  urinary  products  being  rare.      The  cysts  are 
lined   with   flat  polygonal  epithelial  cells,    and  are  sur- 
xounded  with  a  thick  bed  of  coarse  connective  tissue.      In 
spite  of  the  apparent  destruction  of  the  kidney  tissue,  it 
is  remarkable  to  find   on   microscopic  examination  how 
many   tubules   have   been  spared.      With  regard  to  the 
origin  of  the  disease,  some  refer  it  to  an  alteration  in  the 
Malpighian  bodies,  others  to  occlusion  of  the  renal  tu- 
bules.   Mr.  'E^e  (PatJiological  Society's  Transactions,  1880), 
who,  in  a  case  reported  by  him,  paid  attention  to  this 
point,  states  positively  that  the  glomeruli  were  not  per- 
ceptibly altered  in  sections,  which  showed  distinct  dilata- 
tion of  immediately  adjoining  tubes  ;  whilst  the  stages  of 
transition  from  simple  dilatation  of  the  tubule  to  the  for- 
mation of  cyst-like  cavities,  could  be  so  plainly  observed, 
as  to  leave  little  doubt  that  cyst  development  took  place 
from  the  tubuli  uriniferi.      In  most  cases,  as  in  this,  the 
disease  is,  however,  too  far  advanced  to  permit  of  con- 
jectures as  to  the  original  cause  of  the  retention,  though 
it  is  probable  it  consists  in  a  chronic  inflammation  of  the 
interstitial  tissue,  leading  at  first  to  occlusion  of  the  ducts 
of  the  pyramids,  and  then  causing  dilatation  higher  up, 
till  the  whole  kidney  is  involved.     When  the  disease  in- 
volves the  glomeruli,  it  will  be  generally  found  that  the 
contents  of  the  cysts  are  not  limpid  and  albuminous,  but 
colloid,  in  this  case  the  capsule  becomes  distended  with 
colloidal  matter,  and  thus  forms  a  more  or  less  solidified 
cyst,  but  these  cases,  which  are  less  frequent  than   the 
limpid  variety,  ought  to  be  considered  rather  as  coUoidal 
than  a  true  cystic  degeneration. 


316  DISEASES    OF    THE    KIDNEY. 

2.  Secondary  Cystic  Formations. — These  are  the  clear 
transparent  looking  cysts  so  constantly  present  in  granu- 
lar kidney.  They  vary  in  size  from  a  pin's-head  to  a 
pigeon's  egg,  the  largest  contain  albumin,  and  sometimes. 
uric  acid  crystals,  they  all  have  minute  masses  of  a  gela- 
tinous character  floating  in  them,  their  walls  are  thin,  and 
are  generally  distinct  from  each  other.  The  view  gener- 
ally held  with  regard  to  their  formation,  is  that  they  are 
formed  by  the  irregular  compression  exercised  by  the  con- 
tracting fibrous  tissue  on  the  urinary  tubule,  or  by  disten- 
sion of  the  capsule  of  a  Malpighian  corpuscle,  owing  to 
obstruction  of  its  outlet  by  compression,  from  contracting 
fibrous  tissue,  or  blockage  by  a  cast.  Eecently  a  view 
has  been  advanced  (Greene,  Heitzmann's  Morphology), 
which  considers  cysts  as  products  of  secondary  changes  of 
medullary  bodies.  The  first  step,  according  to  this  account 
of  the  process,  is  the  formation  of  inflammatory  corpuscles- 
in  the  cortex,  and  pyramidal  substance,  apparently  derived 
from  the  tubular  epithelia.  These  bodies  swell,  become 
pale,  and  by  a  process  of  liquefaction  form  a  hyaline  mass, 
in  which  may  be  found  fine  granular  fibres,  like  those  of, 
myxomatous  tissue.  This  mass  is  bounded  by  unsoftened 
inflammatory  corpuscles.  As  the  cysts  enlarge,  these  gra- 
dually liquefy,  till  a  cavity  containing  a  sero- albuminous- 
fluid  is  formed,  bounded  by  flattened  medullary  corpuscles,. 
from  this  a  fibrous  basis  substance  originates,  which  forms 
the  wall  of  the  cyst. 


Hydro-nephrosis. 

99.    Etiology.  —  It   has   been    objected   that    hydro- 
nephrosis ought  not  to  be  classified  in  connection  with- 
cystic  disease  of  the  kidney,  which  is  supposed  to  refer- 


HYDRO-NEPHROSIS.  317 

only  to  microscopic  degeneration  of  the  organ.  But 
as  Dr.  Pye  Smith  (Path.  Soc.  Trans.,  vol.  sxiii.)  has 
justly  replied,  that  an  obstruction  to  the  ureter  producing 
either  a  large  single  cavity,  or  a  multilocular  one,  may  be 
fairly  described  as  cystic  disease,  and  that  every  gradation 
in  the  form  and  character  of  cystic  development  may  be 
observed  between  a  simple  hydro-nephrosis  and  a  granular 
kidney  full  of  microscopic  cysts; 

Hydro-nephrosis  then,  may  be  defined  as  a  cystic  disease 
of  the  kidney,  following  on  dilatation  of  the  ureters  and 
the  pelvis  of  the  kidney,  and  attended  with  more  or  less 
destruction  of  the  renal  tissue.  The  obstructions  that 
produce  the  original  dilatation  of  the  ureter  and  pelvis 
of  the  kidney  are  numerous.  Out  of  forty- seven  cases 
collected  by  Mr.  Henry  Morris  {Med.  Chir.  Trans.,  vol. 
lix.),  twelve  were  due  to  impaction  of  calculous  matter ; 
in  five  the  obstruction  was  caused  by  the  abnormal  course 
of  the  ureter  ;  in  five,  it  was  impervious  ;  in  two,  simply 
narrowed,  probably  from  congenital  causes ;  in  two  it 
was  compressed,  one  by  tumour,  and  in  the  other  by  an 
•  abnormal  branch  of  the  renal  artery ;  in  two,  the  obstruc- 
tion was  caused  by  a  valvular  flap  of  mucous  membrane 
at  the  orifice  of  the  ureter ;  in  one  case,  the  compression 
was  caused  by  a  band  of  fibrous  tissue  passing  from  the 
brim  of  the  pelvis  to  the  sacrum;  whilst  in  nineteen  cases, 
the  cause  of  the  obstruction  was  not  mentioned  or  not 
discovered.  Ebstein  lays  a  particular  stress  on  the  con- 
nection that  subsists  between  hydro-nephrosis  and  the 
pathological  conditions  of  the  female  genital  apparatus  as 
caused  by  pressure  from  tumours,  etc.  It  may  also  be 
caused,  not  by  direct  obstruction  by  pressure,  but  by  dis- 
placement and  traction  on  the  ureter  by  the  tumour. 
Obstruction  to  the  flow  of  urine  from  the  bladder  by  en- 
larged prostate,  or  from   stricture,   has   been   spoken  of 


318  DISEASES    OF    THE    KIDNEY. 

as  causing  liydro-nepbrosis ;  but  the  condition  is  rather 
one  of  sacculation  than  the  formation  of  a  cyst  containing 
fluid. 

100.  Symptoms  dejoend   very  much  ux^on  the   mode 
of    origination.      Thus    when    it  follows   upon    uterine 
disease    no    symptoms    may   be    noticeable   during   life. 
As   Mr.    Morris   observes:     "Numerous  cases   of  cancer 
of  the  pelvic  organs  are  treated  annually  in  the  Middle- 
sex Hospital,  yet  none  of  the  present  surgeons  can  re- 
member to  have  seen  a  single  instance  in  which  disten- 
sion of  the  pelvis  of  the  kidney  could  be  detected  by  an 
abdominal  swelling  during   life  ;    yet  hydro-nephrosis  is 
almost  weekly  seen  in  the  post-mortem  room."     This,  no 
doubt,  is  owing  to  the  fact  that  the  ureter  in  these  cases 
is  never  quite  occluded,  and  therefore  the  pressure  effects 
do  not  lead  to  extreme  distension  of  the  kidney  so  as  to  be 
detected  during  life.     It  is  when  the  occlusion  is  more  or 
less  permanent  and  complete,  and  has  come  on  suddenly, 
that  the  hydro-ne^Dhrotic  distension  of  the  kidney  acquires 
a  considerable  size,  and  these  cases  are  those  in  which  the 
obstruction  is  high  up  in  the  ureter,  rather  than  when  it 
is  situated  near  the  bladder.     Mr.  Morris  is  of  opinion 
that  when  an  abdominal  swelling  can  be  detected,  there 
has  been  either  sudden  and  complete  obstruction  to  the 
urine  secreted  by  a  kidney  in  full  function,  or  else  after 
one    kidney   has    undergone   compensatory   hypertrophy, 
some  obstacle  has  arisen   to   the   flow   of  urine   in   the 
hypertrophied  organ.     The  tumour  thus  formed  may  be 
enormous,  and  seriously  compress  both  the  thoracic  and 
abdominal  viscera.     By  its  pressure  on  the  colon  it  often 
causes  serious  obstruction  of  the  bowels.      The  tumour  is 
painless  when  handled,  though  often  the  seat  of  cutting, 
stabbing  pains  ;  fluctuation  can  generally  be  determined, 
and  frequently  after  handling  by  the  physician  or  surgeon, 


HYDRO-NEPHROSIS.  319 


the  contents  are  discharged  into  the  bladder,  catismg  an 
abundant  flow  of  urine.  Hematuria  and  albuminuria 
may  be  occasionally  present,  but  they  are  by  no  means 
constant  symptoms.  The  urine  is  not  dimimshed  m 
quantity  unless  both  kidneys  are  affected,  the  sound  organ 
doing  the  work  of  the  obstructed  one ;  indeed,  the  dis- 
charge is  often  over-copious  from  the  contents  of  hydro- 
nephrosis discharging  into  the  bladder. 

101.  Diagnosis.— During   the   whole  progress  of  the 
disease  the  urine  may  remain  imaffected  in  quality,  but 
the  diagnosis  is  tolerably  certain,  if,  with  a  renal  tumour, 
we  have  intermittent  discharges  of  pale  aqueous  urine. 
The  tumours  likely  to  be  taken  for  hydro-neplnrosis  are 
ovarian  cysts,  hydatids  of  the  kidney,  and  ascites.     The 
former  may  generaUy  be  determined  by  examination  by 
the  vagina  and  rectum.     This  latter  examination  should 
be  performed  by  introducing  the  hand  into  the  rectum, 
and  exploring  with  the  finger   the   whole   of  the   upper 
pelvic  region.     By  alternately   compressing   the   ureters 
with  Davy's  rectal  lever  we  can  also  learn  whether  urine 
is  being  discharged  by  both,  or  whether  it  is  obstructed 
in  one.     If  the  urine  is  q^dte  obstructed  in  one,  we  may 
be  tolerably   confident   that   the   case   is  one   of  hydro- 
nephrosis, and  not  ovarian.      The   history  of  theh:   de- 
velopment,  and   a   careful  consideration  of  the  relation 
of  the  tumour  to  the  intestines,  will  also  aid  in  form- 
ing our  opinion.     Withdrawal  of  smaU  portions  of  the 
contents   of  the  tumour   will  decide   if  there  should  be 
doubt,   as   also  will  be    the    case    with   an   hydatid  tu- 
mour.    In  ascites,  dulness  will  always  be  found  in  the 
most  dependent  part,  whereas  in  hydro-nephrosis  the  dul- 
ness always  remains  locahzed,  in  whatever  position  the 
patient  may  be  placed.      Solid  tumours  of  the  kidney  may 
be  distinguished  from  hydro-nephrosis   by   the   want   of 


320  DISEASES    OF    THE    KIDNEY. 

fluctuation  and  tlieir  irregular  and  nodulated  contour.  It 
is  sometimes  difficult  to  determine  between  pyo-nephrosis 
and  hydro-nephrosis.  In  the  former,  however,  we  have 
generally  the  history  of  preceding  pyelitis  and  the  occa- 
sional discharge  of  pus  and  blood,  considerable  constitu- 
tion disturbance,  and  often  a  fluctuating  temperature ; 
whilst  in  hydro-nephrosis  the  early  history  is  often  ob- 
scure, the  symptoms  have  come  on  insidiously,  there  is 
little  constitutional  disturbance,  and  the  discharge,  when 
it  occurs,  is  aqueous. 

102.  Morbid  Anatomy. — The  degree  of  dilatation 
of  the  pelvis  of  the  kidney,  and  the  destruction  of 
its  tissue,  depends  on  the  completeness  of  the  ob- 
struction, whilst  the  form  of  the  tumour  is  determined 
by  the  position  of  the  obstruction.  If  situated  low  down, 
as  in  the  bladder,  the  distension  of  the  ureter,  pelvis 
and  capsule  assumes  a  somewhat  fusiform  shape,  the 
ureter  in  some  instances  resembling  small  intestine 
both  in  size  and  sacculated  appearance.  When  the  ob- 
struction is  higher  up  in  the  ureter,  the  tumour  assumes 
a  rounded  pyramidal  shape,  the  apex  being  formed 
by  the  obstructed  part  of  the  ureter.  The  tumour  may 
consist  of  only  one  single  cavity,  more  frequently  of 
several,  each  opening  into  the  pelvis  of  the  kidney  and 
corresponding  to  the  dilated  calyces.  When  the  ob- 
struction is  complete  and  long  continued,  every  vestige 
of  renal  tissue  may  disappear  and  nothing  left  but  a 
membranous  sac.  The  first  change  in  the  renal  tissue 
is  flattening  of  the  papillae  and  dilatation  of  the  calyces, 
whilst  the  medullary  substance  atrophies,  till  at  length 
under  the  long-continued  pressure  of  the  confined  secretion 
the  cortex  dwindles  and  disappears,  though  this  process  is 
slow,  owing  as  we  have  seen  (p.  279),  to  the  overgrowth 
of  the  interstitial   connective   tissue,   which,  for  a  time 


HYDRO-NEPHROSIS.  321 

resists  tlie  undue  pressure  in  the  tubules.  When  the  ob- 
struction at  first  is  slight  and  only  gradually  increases,  no 
great  dilatation  may  ensue,  and  may  proceed,  supposing 
the  obstruction  never  becomes  quite  complete,  no  further 
than  to  atrophy  of  the  medullary  substance.  Even  then 
if  complete  obstruction  sets  in,  and  the  Iddney  structure 
is  absolutely  wasted,  the  hydro-nephrosis  never  attains 
considerable  dimensions,  because  the  destruction  of  the 
secreting  structure  has  gone  hand  in  hand  with  the  ob- 
struction. It  is  sudden  and  complete  obstruction  that 
leads  to  large  hydro-nephrotic  tumours.  The  fluid  of 
hydro-nephrosis  is  of  low  specific  gravity  1'004  with  a 
neutral  or  slightly  acid  reaction,  never  alkaline  unless  it 
has  been  kept,  it  generally  contains  traces  of  urea  and  uric 
acid  though  these  may  be  absent.  It  does  not  contain 
albumin,  though  Dr.  Schetelig  of  Hamburg  has  found 
par- albumin  in  the  fluid  of  a  hydro-nephrosis,  cholesterin 
has  also  been  found.  The  fluid  contains  an  abundance  of 
sodium-chloride.  In  many  respects  it  resembles  the  fluid 
of  an  hydatid  cyst,  that  however  has  usually  a  higher  spe- 
cific gravity,  1-009  to  1-013;  its  reaction  is  usually  faintly 
alkaline ;  the  sodium- chloride  is  much  more  abundant  than 
that  found  in  hydro-nephrosis  or  any  other  fluid  in  the 
body,  whether  healthy  or  morbid ;  lastly,  it  never  contains 
urea  or  uric  acid,  whilst  the  presence  of  booklets  can 
generally  be  made  out.  The  fluid  of  a  hydro-nephroEis 
often  contains  pus,  sometimes  it  becomes  rapidly  purulent 
so  that  the  condition  becomes  that  of  a  true  pyo-nephrosis. 
Hydro-nephrosis  is  usually  confined  to  one  kidney,  the 
other  becoming  hypertrophied  in  consequence  of  the 
double  duty  thrown  on  it.  If  both  kidneys  are  affected 
they  are  generally  unequally  so.  "When  the  disease  re- 
sults from  congenital  malformation  of  the  ureter,  there  is 
usually  some  other  abnormality  of  development  noticed, 


322  DISEASES    OF    THE    KIDNEY. 

as    club-foot,   -webbed  toes   and    fingers,   hare-lip,   cleft 
palate,  etc. 

103.  Treatment. — If  the  disease  arises  from  sudden 
obstruction  as  from  the  impaction  of  a  calculus,  we  may 
hope  if  the  obstruction  is  speedily  removed,  that  beyond 
dilatation  of  the  pelvis  of  the  kidney,  no  great  damage  has 
been  done  to  the  renal  tissue.  Even  in  cases  where  it  is 
impossible  to  effect  the  removal  of  the  obstruction-,  great 
good  may  result  by  endeavouring  to  relieve  the  pres- 
sure or  tension  on  the  ureter.  Thus  in  cases  of  hydro- 
nephrosis arising  from  tumours  in  the  pelvic  region,  the 
thorough  emptying  of  the  lower  bowel  every  day;  sup- 
porting, when  possible,  the  tumour,  as  in  prolapsed 
uterus  or  fibroid  of  that  organ,  by  means  of  pessaries, 
etc.,  introduced  into  the  vagina  ;  by  keeping  the  patient 
in  a  posture  that  shall  diminish  the  pressure  or  traction 
of  the  tumour '  on  •  the  ureter,  to  the  greatest  possible 
degree.  In  those  cases  in  which  the  obstruction  is  so 
great  as  to  resist  the  onward  pressure  of  the  accumulated 
fluid,  but  not  so  complete  as  to  resist  any  additional  force, 
such  as  may  be  produced  by  pressure  with  the  hand, 
great  relief,  and  in  a  few  instances  a  cure,  has  been 
effected,  by  daily  emptying  the  sac  by  gently  squeezing  it, 
and  then  applying  a  flannel  roller  firmly  round  the  abdo- 
men. In  applying  this  mode  of  treatment,  care  must  be 
taken  not  to  apply  the  pressure  too  suddenly  but  gently 
and  uniformly,  otherwise  there  is  danger  of  rupturing  the 
sac.  Lastly,  if  the  tumour  is  rapidly  increasing  and  can- 
not be  emptied  by  ordinary  pressure,  surgical  means  must 
be  employed,  mere  puncture  and  withdrawal  of  the  fluid 
gives  sufficient  relief  in  some  of  these  cases,  but  in  others, 
especially  if  the.  cause  of  the  obstruction  be  an  impacted 
calculus  and  the  sac  after  having  been  tapped  speedily 
refills,  it  is  advisable  to  have  recourse  to  more  effectual 


DEKMOID    CYSTS.  323 

means  aud  to  make  an  incision  througli  the  loin  into  the 
distended  pelvis  of  the  kidney,  when  the  calculus  may  be 
removed,  or  possibly  even  a  stricture  due  to  an  abnormal 
fold  of  mucous  membrane  at  the  upper  orifice  of  the 
ureter  may  be  dealt  with ;  or  the  entire  organ  may  be 
removed.  The  details  connected  with  the  operative  pro- 
cedures required  for  puncture,  nephrectomy  or  nephro- 
tomy belong  entirely  to  the  province  of  surgery,  and 
cannot  be  discussed  in  this  work.  In  making,  how- 
ever, an  exploratory  puncture  with  an  aspirator  for  the 
purpose  of  withdrawing  fluid  for  examination,  we  should, 
unless  there  is  a  decided  prominent  fluctuating  spot  where 
the  skin  is  discoloured  or  the  sac  thin,  in  the  case  of  the 
left  kidney,  insert  the  trocar  in  the  interval  between  the 
two  last  ribs  near  their  anterior  extremities,  a  situation 
originally  proposed  by  Mr.  J,  Thompson  of  Nottingham. 
WhUst  for  the  right  kidney,  Mr.  Morris  proposes  a  spot 
half-way  between  the  last  rib  and  the  crest  of  the  ihum, 
between  two  inches,  or  two  inches  and  a  half,  behind  the 
anterior  superior  spine  of  the  ilium. 


Dermoid  Cysts. 

104.  Dermoid  Cysts,  although  frequently  discharging 
into  the  urinary  passages,  are  rarely  found  actually  exist- 
ing in  the  kidneys  or  walls  of  the  urinary  passages.  Their 
structure  is  peculiar,  consisting  of  an  outer  coat  or  fibrous 
envelope,  and  an  inner  layer  of  cuticular  tissue.  This 
is ,  smooth,  but  having  irregular  prominences  scattered 
throughout.  The  epithelium  consists  of  layers  of  cells,  the 
superficial  are  flattened  and  nucleated,  the  deeper  iDoly- 
gonal  and  rounded.  Occasionally  under  the  epithelial 
layer,  papillse  may  be  observed  in  the  cutis.     Between  this 

y2 


324  DISEASES    OF    THE    KIDNEY. 

layer  and  the  external  coat  is  a  little  fine  adipose  tissue. 
The  contents  of  the  cysts  are  composed  of  a  dirty  yellowish 
pultaceous  fluid,  consisting  of  fatty  and  sehaceous  matter, 
epithelial  cells,  and  crystals  of  cholesterin.  Imbedded  in 
this  will  be  found  remains  of  bone,  teeth,  hair,  and  some- 
times stripped  muscular  fibres  and  nerve-tissue.  In  a 
case  brought  under  my  observation,  the  cyst  was  appar- 
ently connected  with  the  right  spermatic  cord,  forming  a 
hernia-like  protrusion  in  the  inguinal  canal,  in  fact  it  was 
at  first  taken  for  a  hernia  and  was  found  to  be  irreducible. 
The  child  became  ill  and  feverish  and  the  urine  thick  and 
albuminous,  and  the  swelling  disappeared.  The  urine 
then  cleared  up  and  ceased  to  contain  albumin,  no  teeth 
or  bone  were  discharged,  but  when  the  urine  became  clear 
it  was  noticed  that  from  time  to  time  an  abundance  of 
fine  hair  was  passed  with  the  urine.  This  hair  collected 
and  examined,  consisted  of  three  varieties  of  hairy  matter 
mingled  together ;  very  fine,  short  straight  hairs  closely 
matted  together  by  a  sticky  sebaceous  substance  and 
having  somewhat  the  appearance  of  felt,  short  crisp  curly 
hairs  somewhat  resembling  wool,  and  some  longer  fibres, 
resembling  in  all  respects  human  hair.  These  latter 
varied  in  length  from  about  a  quarter  of  an  inch  to  two 
inches,  and  were  coloured  either  a  deep  coal-black  or 
else  a  bright  vermilion-red,  they  comprised  about  one- 
tenth  of  the  whole  mass  of  hair.  The  amount  discharged 
varied  considerably,  for  some  days  no  hair  would  be  de- 
posited and  then  an  abundance  would  come  away.  This 
discharge  of  hair  caused  the  patient  no  discomfort,  and 
the  child  had  no  apparent  irritability  when  it  passed 
water.  I  therefore  advised  the  parents  not  to  trouble  about 
the  matter  at  present,  but  to  keep  the  child  under  medical 
supervision,  when  if  any  chronic  irritability  of  the  bladder 
arose,  either  from  the  irritation  x^i'oduced  by  the  constant 


FATTY   DEaENERATION.  325 

XDresence  of  foreign  bodies  in  the  bladder,  or  from  calculous 
deposit  round  any  hairs  that  had  not  come  away,  surgical 
interference  might  be  required.  The  peculiar  character 
of  the  hairy  matters  discharged  is  sufficient  to  indicate 
the  nature  of  the  case,  and  to  distinguish  them  from  hairy 
substances  purposely  or  accidentally  introduced  into  the 
urine.  The  peculiar  felt-like  substance,  in  which  woolly 
and  long  straight  hairs  are  intermixed,  and  the  peculiar 
bright-red  colour  of  some  of  the  latter,  are  alone  character- 
istic of  hairs  discharged  by  dermoid  cysts. 


Fatty  Degenekation. 

105.  Fatty  Degeneration  of  the  kidney  epithelia 
may  be  either  acute  or  chronic.  The  most  acute  forms 
are  those  associated  with  phosphorus  poisoning,  and  other 
toxic  agents,  such  as  sulphuric  acid,  oxalic  acid  and  car- 
bonic oxide ;  certain  morbid  conditions,  as  in  ulcerative 
endocarditis  of  acute  rheumatism,  after  extensive  burns, 
pernicious  anaemia,  and  diabetic  coma,  and  that  condition 
not  yet  determined,  which  leads  to  acute  yellow  atrophy 
of  the  liver.  The  chronic  forms  are  the  fatty  changes  that 
occur  in  the  epithelium  in  Bright's  disease,  and  the  fatty 
infiltration  observed  in  chronic  phthisis  and  other  wasting 
diseases. 

The  acute  fatty  changes  occur  chiefly  in  the  convoluted 
portion  of  the  tubules,  and  is  often  so  limited  to  them 
that  a  distinct  line  of  demarcation  can  be  made  out 
between  the  straight  and  convoluted  portions  of  the  tu- 
bules. Though  the  straight  portion  may  be  afi^ected 
it  is  not  so   marked.      The   swelling   of  the   epithelium 


326  DISEASES    OF    THE    KIDNEY. 

causes  some  slight  enlargement  of  the  organ  at  first,  but 
as  desquamation  proceeds  the  kidney  diminishes  in  bulk 
from  the  discharge  of  the  degenerated  cells.  On  making  a 
section  of  a  kidney  undergoing  acute  fatty  changes,  the 
cortex  presents  a  greyish-yellow  colour,  often  much 
mottled,  the  pyramids  congested.  In  septic  cases  the 
organ  is  very  much  softened  throughout,  and  in  some 
cases,  as  in  embolism  of  the  renal  artery,  necrosis  of 
the  kidney  may  result.  In  this  case,  the  whole  of 
the  cortical  substance,  and  some  portion  of  the  pyrami- 
dal, are  converted  into  a  dry  greyish  opaque  mass,  in 
which  dark  red  •  spots  irregularly  distributed  may  be 
observed.  These  spots  correspond  to  the  Malpighian 
corpuscles,  which  are  the  only  vessels  in  the  kidney  that 
contain  blood  in  suf&cient  quantity  to  cause  distension ;  the 
veins  of  the  kidney  either  being  empty,  or  containing  only 
a  Httle  thin  bloody  fluid.  No  special  symptoms  indicate 
the  occurrence  of  acute  fatty  degeneration  of  the  kidney. 
Albuminuria  may  be  i^resent,  but  it  is  not  infrequently 
absent  (see  p.  163).  Fatty  cells  may  appear  in  the  urine 
if  the  patient  survive  the  attack  a  few  days,  but  they  are 
rarely  noticed  in  the  early  acute  stage,  though  I  have  seen 
free  fat  in  small  quantities,  in  the  urine  of  a  patient  dying 
of  acute  diabetic  coma  (acetonemia).  As  acute  fatty 
degeneration  of  the  kidney  is  generally  associated  with 
fatty  degeneration  of  other  organs,  especially  the  liver,  we 
often  find  the  character  of  these  derangements  expressed 
in  the  urine.  Thus,  in  acute  yellow  atrophy  of  the  liver, 
or  after  phosphorus  poisoning,  we  find  the  urine  contain- 
ing bile,  and  products  of  imperfect  proteid  metabolism, 
to  wit,  leucin  and  tyrosin.  "With  respect  to  these  consti- 
tuents the  composition  of  the  urine  varies  at  different 
stages  of  the  disease.  At  first,  during  the  period  of 
hyperasmia,  we  find  the  urea  either  normal  in   quantity 


PAEENCHYMATOUS    DEGENERATION.  327 

or  perhaps  slightly  augmented,  whilst  both  bile  pig- 
ments and  bile  acids  are  present  in  the  urine  and  but 
rarely  leucin  and  tyrosin.  As  the  destruction  of  the  liver 
cells  advances,  the  amount  of  urea  rapidly  diminishes,  till 
only  a  fourth  of  the  normal  quantity  may  be  observed, 
and  it  is  then  that  leucin  and  tyrosin  are  most  abundant, 
whilst  the  quantity  of  bile  considerably  diminishes  ;  the 
pigment  being  only  represented,  the  bile  acids  being 
usually  absent ;  the  dark  colour  of  the  urine  observed  at 
this  stage  being  due  to  a  very  great  relative  and  absolute 
excess  of  urates.  Albumin  may  or  may  not  be  present  in 
these  cases. 

The  nature  of  the  changes,  in  chronic  fatty  degeneration 
of  the  kidneys,  is  described  in  connection  with  the  atrophic 
changes  observed  in  chronic  nephritis  (p.  217). 

106.  Parenchymatous  Degeneration,  or  as  it  is 
sometimes  called,  molecular  or  granular,  consists  in  a 
"cloudy  swelling"  of  the  renal  epithelium,  similar  to 
what  is  observed  in  acute  tubal  nephritis.  Indeed  most 
authorities  consider  the  two  conditions  identical,  and  that 
cloudy  swelling  is  the  first  step  in  acute  Bright's  disease. 
Professor  Greenfield  defines  the  relation  between  the  two  in 
perhaps  a  more  exact  manner,  when  he  says,  that  whilst 
parenchymatous  degeneration  occurs  at  the  onset  of  acute 
Bright's  disease,  and  other  morbid  conditions,  it  is  not 
the  essence  of  the  disease  but  only  the  common  re- 
sult of  different  processes.  This  "  cloudy  swelling " 
is  noticed  in  those  who  have  died  of  febrile  diseases, 
such  as  pneumonia,  typhus,  enteric  and  scarlet  fevers 
acute  rheumatism,  in  which  the  temperature  is  raised 
for  some  time  above  the  normal.  It  may  give  rise  to 
no  symptoms  during  life,  though  a  trace  of  albumin  is 
nearly  always  present  in  febrile  urines,  and  which  no 
doubt  results  from  the  disordered  function  of  the  renal 


328  DISEASES    OF    THE    KIDNEY. 

epitlielmm.  It  is  interesting  to  observe  in  these  cases 
how  a  rise  in  the  temperature  is  followed  by  an  increase 
of  albumin  in  the  urine.  Cloudy  swelling  is  also  found  in 
other  specific  diseases,  giving  rise  to  albuminuria  as  in 
cholera,  diphtheria,  erysipelas,  etc. 

The  kidneys  in  febrile  cases  are  more  or  less  swol- 
len, especially  the  cortex  which  is  generally  slightly  con- 
gested and  of  a  pinkish  colour.  The  epithelium  of  the 
convoluted  tubes  is  swollen  and  granular,  whilst  the  epi- 
thelium of  the  straight  tubes  is  rarely  found  to  have 
undergone  any  apparent  change. 

Some,  however,  drawing  their  conclusions  from  the 
result  of  experiments  on  animals,  in  whom  the  py- 
rexial  state  was  artificially  induced,  deny  that  renal 
hyperemia  is  occasioned  by  the  pyrexial  state,  but  on 
the  contrary  they  maintain  the  condition  to  be  one 
of  anaemia,  and  that  instead  of  the  kidney  being  slightly 
swollen  it  undergoes  a  diminution  in  bulk.  This  con- 
dition they  consider  is  brought  about  by  contraction 
of  the  walls  of  the  blood-vessels,  and  is  constant  and  pro- 
gressive, being  pro^Dortionate  to  the  amount  of  the  fever ; 
the  contraction  of  the  vessels  is  brought  about,  they 
believe,  by  a  stimulus  originating  in  the  central  nervous 
system,  probably  the  hot  blood  circulating  there.  This 
view  has  received  considerable  support,  and  is  very  ably 
stated  by  Dr.  Mendelson  in  an  article  on  the  Eenal  Cir- 
culation during  fever  [American  J  owned  of  the  Medical 
Sciences,  No.  172,  1883). 

107.  Calcareous  Degeneration. — In  old  persons, 
or  in  patients  sufi"ering  from  osteomalacia,  deposits  of 
carbonate  of  lime  are  often  found  in  the  straight  por- 
tion of  the  urinary  tubules,  and  in  the  inter-tubular 
tissue,  giving  rise  to  white  streaks  extending  from  the 
papillae  to  the  basis  of  the  pyramids,  very  much  re- 


SYPHILITIC   INFILTEATION.  329' 

sembling  the  infarcts  of  sodium  urate  observed  in  tlie 
kidneys  of  newly-born  infants,  and  the  sodium  urate  in 
the  kidneys  of  gouty  patients.  They  are  distinguished, 
from  these  by  effervescing  when  treated  with  dilute  acid, 
and  not  giving  the  murexide  reaction.  The  carbonate  of 
lime  is  generally  arranged  in  small  nodular  masses,  in  the 
form  of  small  balls,  and  usually  contains  in  addition  some 
phosphate  of  lime  mixed  with  organic  matter.  Another 
form  of  calcareous  deposit,  is  described,  as  occurring 
in  the  waUs  of  the  renal  vessels  and  surroundmg  fibrous 
tissue,  which  becomes  infiltrated  with  a  gritty  material 
resembhng  sand. 


Syphilitic  Infiltration. 

108.  Syphilis  is  an  important  etiological  factor  in 
relation  to  the  development  of  lardaceous  disease  (p. 
301),  but  syphilitic  deposits  are  not  so  common  in  the 
kidneys  as  in  other  oi-gans.  When  met  with  they  occur 
in  roundish  irregular  nodulated  masses  rarely  exceed- 
ing half  an  inch  in  diameter,  situated  in  the  cortex 
of  the  organ,  they  have  a  yellowish  appearance,  and 
are  somewhat  tough  and  hard,  owing  to  caseous  changes, 
yielding  little  or  no  fluid,  though  in  an  early  stage  they 
may  be  more  gelatinous  ;  they  consist  of  a  number  of 
small  cells  imbedded  in  an  obscurely  fibrillated  tissue. 
In  the  central  portion  the  cells  are  for  the  most  part 
broken  down  and  converted  into  granular  debris  and  fat 
granules,  whilst  the  fibrillated  tissue  is  scanty.  The 
outer  portion  of  the  gumma  is  highly  cellular,  and  the 
fibro-nucleated  structure  more  evident,  the  cells  are 
mostly  small,  like  white  blood  corpuscles,  whilst  some  are 
larger  and  nucleated  ;  between  the  cells  is  a  scanty  homo- 


330 


DISEASES    OF    THE    KIDNEY. 


geneons  stibsfance  containing  new  blood  vessels,  wLicli 
rapidly  become  obliterated  as  the  process  advances.  The 
central  portion  of  the  growth  may  become  calcified,  but 
more  usually  the  degenerated  jDroducts  are  absorbed  and 
nothing  is  left  but  the  external  fibrillated  structure,  which 
by  contraction  forms  a  fibrous  cicatrix.  These  scars  are 
generally  present  in  the  kidneys  the  seat  of  gummatous 
deposit  and  are  evidences  of  previous  formations,  the 
Iddneys  too  are  almost  always  the  seat  of  lardaceous  de- 
generation. Syphilitic  disease  of  the  arteries  of  the  kidney 
may  be  observed  in  association  with  gummatous  growths 
or  independent  of  them.  Syphilitic  disease  of  the  arteries 
consists  in  the  infiltration  of  the  inner  coat  of  the  vessel 
with  a  cellular  growth  of  small  round  and  spindle-shaped 
cells,  resembling  ordinary  granulation  tissue,  this  in- 
filtration •  of  course  diminishes  very  considerably  the 
lumen  of  the  arteries,  and  by  interfering  with  the  cir- 
culation leads  to  softening  of  the  parts  supplied  by 
them.  The  obliteration  of  the  new  blood-vessels  of  a 
gumma  is  effected  in  this  manner,  and  their  destruction 
is  followed  by  the  rapid  softening  of  the  centre  of  the 
growth.  Syphilitic  disease  of  the  kidney  may  exist  with- 
out giving  rise  to  any  symptom ;  as,  however,  it  is  nearly 
always  associated  with  lardaceous  degeneration,  albu- 
minuria will  generally  be  observed.  Albuminuria,  occur- 
ring in  a  i^erson  the  subject  of  syphilis,  requires  specific 
treatment,  for  this  purpose  large  doses  of  iodide  of  x^otas- 
sium  are  generally  relied  on,  commencing  with  ten  and 
gradually  rising  to  twenty  grains  three  times  a  day,  but  I 
have  often  known  the  albuminuria  to  continue  till  mer- 
curial preparations  have  been  employed.  They  must, 
however,  be  given  with  extreme  care,  since  mercury  is 
badly  borne  when  the  kidneys  are  the  seat  of  waxy  de- 
generation, the  best  j)lan  is  to  give  it  in  the  form  of  grey 


SCROFULOUS    KIDNEY.  331 

powder  combined  with  Dover's  powder,  one  grain  of  each 
twice  a  day,  stopping  it  as  soon  as  any  tenderness  of  the 
gums  is  experienced  and  resuming  it  as  soon  as  its  influ- 
ence seems  to  have  subsided.  In  this  v»"ay  I  have  been 
able  to  maintain  a  course  of  mercury  for  several  weeks, 
with  most  satisfactory  results.  With  the  mercurial,  cod- 
liver  oil  and  syrup  of  the  iodide  of  iron  should  be  given. 


SCEOFULOUS    InFILTEATION. 

109.  Etiology. — Scrofulous  inflammation  of  the  kidney 
may  occur  at  any  period  of  life.  According  to  Eoberts  it 
is  most  frequent  during  middle  age.  This  is  contrary  to 
my  experience,  which  would  lead  me  to  fix  from  twelve 
to  twenty-five  years  of  age  as  the  epoch  of  hfe  during 
which  it  is  most  likely  to  occur.  But  my  cases  occurred 
for  the  most  part  among  sailors  at  the  "Dreadnought," 
lads  from  training  ships,  and  the  inmates  of  a  workhouse 
infirmary,  which  no  doubt  accounts  for  the  difference. 
It  is  very  much  more  frequent  among  males,  for  two 
reasons:  first,  because  males  are  more'  exposed  by 
their  occupations  to  causes  likely  to  set  up  inflam- 
mation ;  secondly,  because  in  the  male  the  liability  of 
secondary  extension  from  the  generative  organs  is  more 
frequent ;  whilst  in  the  female,  though  scrofulous  dis- 
ease of  the  urinary  organs  may  extend  to  the  generative 
organs,  it  is  an  extremely  rare  event  for  scrofulous  in- 
flammation after  attacking  the  generative  organs,  to  in- 
volve the  bladder  and  kidneys.  The  predisposition  to 
scrofulous  inflammation  is  no  doubt  usually  inherited, 
though  it  is  often  difficult  to  trace  a  direct  history ;  whilst 
the  exciting  cause  is  generally  attributed  to  cold.  Indeed, 
cold  is  the  only  cause  alluded  to  by  Eoberts  and  Ebstein. 


332  DISEASES    OF    THE    KIDNEY. 

In  cases,  however,  in  ■whicli  the  disease  was  unilateral,  I 
have  known  it  follow  on  strumous  deposit  in  the  testicle 
and  cord  of  the  same  side,  in  one  case  ;  after  a  blow,  or 
strain  of  the  loin,  in  two  cases  ;  after  over-distension  of 
the  bladder  for  some  hours,  the  result  of  comxHilsory  re- 
tention, in  this  case  there  must  have  been  some  previous 
tubercular  deposit  in  the  bladder  or  prostate ;  and,  in  one 
case  it  followed  immediately  on  the  disappearance  of  an 
eczema  affecting  the  inner  sides  of  both  thighs.  This 
X^atient  subsequently  died  of  phthisis. 

110.  Symptoms. — When  the  kidney  is  the  organ  first 
attacked,  the  earliest  symptoms  are  those  of  pyehtis, 
usually  followed,  sooner  or  later,  by  cystitis.  There  is 
pain  in  the  loins,  but  this,  unlike  what  occurs  in  calculous 
pyelitis,  is  rarely  reflected  downwards  into  the  thighs  or 
testicles,  nor  has  it  the  paroxysmal  character,  being 
mostly  dull,  aching,  and  continuous.  Should  the  pain 
become,  at  any  time,  paroxysmal,  it  is  generally  asso- 
ciated with  a  diminution  of  the  amount  of  pus  in  the 
urine,  and  indicates  a  blockage,  temporary  or  otherwise, 
of  the  ureter,  on  the  side  the  pain  occurs,  with  some  of 
the  cheesy  mass.  When  the  disease  involves  the  bladder, 
symptoms  of  cystitis  set  in.  No  reliance,  however,  should 
be  placed  in  mere  increased  hritability  of  that  organ, 
since,  as  with  renal  calculus,  a  considerable  degree  of 
vesical  irritabihty  and  even  strangury  may  be  present 
without  the  bladder  being  in  any  way  diseased.  The  only 
rehable  sign  is  the  character  of  the  urine,  which  from  being 
acid  and  almost  enth'ely  x)urulent,  may  become  alkaline, 
and  the  pus  mixed  with  an  excess  of  mucus.  When  the 
disease  commences  in  the  bladder,  and  then  extends  up- 
wards to  the  kidney,  it  is  often  very  difficult  at  first  to 
determine  that  it  has  occuirred,  and  it  may  indeed  escape 
observation  entirely.      The  enlarged  kidney  may  usually 


SCROFULOUS    KIDNEY.  333 

be  felt  in  the  loins  and  flank,  though  in  ordinary  cases  if 
the  ureters  are  free  it  rarely  attains  a  large  size.  If, 
however,  the  passage  of  the  purulent  fluid  be  arrested, 
and  pyo-nephrosis  result,  a  considerable  tumour  may 
form.  If  the  obstruction  be  temporary,  the  size  of  the 
tumour  will  vary  inversely  with  the  amount  of  pus  and 
cheesy  matter  discharged.  Manipulation  of  the  swelling 
generally  aggravates  the  pain.  Fever  of  hectic  character 
is  always  present,  the  elevations  of  temperature  being 
ushered  in  by  chills  followed  by  sweating,  whilst  the 
apyretic  periods  are  of  irregular  duration.  Owing  to  the 
continuance  of  the  fever,  the  patient  rapidly  emaciates, 
the  skin  becomes  dry,  harsh  and  branny ;  digestion  be- 
comes affected,  and  diarrhoea  is  easily  provoked,  and 
checked  with  difficulty.  The  urine  from  the  first  is  al- 
ways more  or  less  turbid  with  pus,  which  comes  away 
uniformly,  or  else  in  sudden  discharges,  according  to  the 
degree  of  obstruction  in  the  ureter  ;  and  when  the  kidney 
is  the  sole  seat  of  the  disease,  the  reaction  is  mainly  acid. 
Blood  is  usually  observed  during  the  early  progress  of  the 
case,  it  is  rarely,  however,  as  excessive,  or  as  constant  as 
in  calculous  pyelitis,  nor  does  it  depend  so  closely  on  un- 
due movements  on  the  part  of  the  patient.  The  epithe- 
lium of  the  pelvis  of  the  kidney,  in  a  swollen  condition,  can 
generally  be  recognised  in  the  urine.  Albumin  is  always 
present,  being  usually  derived  solely  from  the  pus,  and  is 
proportionate  to  the  amount  discharged.  In  some  cases, 
however,  true  albuminuria  has  been  noticed  preceding  the 
onset  of  the  disease  ;  or  as  the  disease  progresses,  diffuse 
nephritis,  with  the  appearance  of  tube  casts,  may  occur. 
The  urine  contains  in  addition  to  the  pus  and  blood,  much 
granular  detritus,  often  fragments  of  cheesy  matter  in- 
soluble in  acetic  acid.  In  these  fragments  the  tubercle 
bacillus  has  been  observed.     Also  occasionally  when  the 


334  DISEASES    OF    THE    KIDNEY. 

disease  is  advanced,  elastic  fibres  from  tlie  destroyed  con- 
nective tissue.  When  the  bladder  is  affected  the  urine 
becomes  muco-purulent,  and  an  alkaline  reaction  generally 
developes. ' 

111.  Diagnosis. — Scrofulous  disease  of  the  kidney  may 
be  taken  for  calculous  pyelitis,  cancer  of  the  kidney,  or 
an  hydro-nephrosis  which  has  become  purulent.  If  the 
bladder  is  also  affected,  chronic  XDrostatic  abscess  may  be 
mistaken  for  it.  From  the  first  it  may  be  distinguished 
by  the  higher  degree  and  character  of  the  pyrexia,  the  less 
paroxysmal  and  radiating  character  of  the  pain,  by  the 
htematuria  being  less  frequent  and  not  following  neces- 
sarily upon  exertion.  From  cancer,  by  the  abundant  dis- 
charge of  pus  and  by  the  pyrexia.  From  a  hydro-nephrosis 
that  has  become  a  pyo-nephrosis,  by  the  history  of  the  case, 
by  the  hectic  character  of  the  pyrexia.  The  presence 
moreover  in  the  urine  of  small  portions  of  caseous  matter, 
insoluble  in  acetic  acid  will  in  all  cases  when  observed 
determine  the  diagnosis  in  favom'  of  scrofulous  inflamma- 
tion; especially  if  the  tubercle  bacillus  be  likewise  observed. 

112.  Morbid  Anatomy. — The  inflammatory  process, 
which,  in  persons  of  a  scrofulous  habit,  tends  to  the  forma- 
tion of  cheesy  masses,  may  commence  at  any  point  in  the 
urinary  tract.  Thus  the  disease  may  begin  in  the  papilla  of 
the  kidney  and  by  extension  upwards  destroy  the  pyramidal 
and  cortical  portion  of  the  organ,  and  by  invasion  down- 
wards the  mucous  surface  of  the  pelvis  of  the  kidney  and 
the  ureter,  or  the  disease  may  commence  in  the  bladder 
and  sj)riug  upwards,  involving  successively  the  ureters, 
the  pelvis  of  the  kidney,  and  the  kidney  itself.  When  the 
disease  is  fully  estabhshed  the  kidney  presents  a  nodular 
and  lobular  appearance,  the  capsule  thickened  and  adher- 
ent in  places,  whilst  scattered  over  its  surface  are  nume- 
rous cheesy  deposits.     On  making  a  section  of  the  organ 


SCROFULOUS    KIDNEY.  335 

we  find  it  converted  into  a  thickened  sac,  irregularly 
divided  by  a  few  septa,  all  opening  freely  into  the  pelvis 
of  the  kidney.  The  kidney  tissue  may  be  completely  de- 
stroyed if  the  disease  is  extensive  and  of  long  standing, 
but  usually  some  remnants  may  be  made  out.  In  some 
cases,  a  fibrillated  and  granular  substance,  attended  at  a 
certain  stage  of  its  progress  with  the  formation  of  masses  of 
cells  round  some  of  the  vessels,  occurs  in  the  cortex  (Path. 
Soc.  Trans.,  1875,  p.  132).  The  pouches  formed  by  the 
membranous  septa  are  filled  with  yellowish  cheesy  masses,, 
undergoing  softening  in  the  centre  ;  or  with  a  pultaceous 
fluid  consisting  of  pus ;  broken  down  caseous  matter  in- 
soluble in  acetic  acid ;  occasionally  small  cysts  containing- 
dark  yellowish  fluid  of  urinous  odour,  and  containing  pus 
cells,  with  triple  phosphate  and  granular  matter,  may  be 
observed.  The  mucous  membrane  of  the  pelvis  of  the  kid- 
ney is  greatly  thickened  with  infiltrated  caseous  matter, 
and  irregularly  ulcerated  where  this  has  broken  down. 
Portions  of  the  destroyed  mucous  membrane,  together 
with  fragments  of  the  subjacent  connective  tissue,  are 
constantly  removed  by  the  urine.  If  the  ureter  is  affected 
it  will  be  found  greatly  thickened,  and  irregtdarly  nodu- 
lated on  its  exterior,  whUst  its  lumen  is  encroached  upon 
by  the  deposit  of  tubercle  in  its  walls  ;  the  mucous  mem- 
brane may  be  ulcerated  in  patches  and  its  upper  portion 
widely  distended  by  plugging  of  the  canal  by  a  portion  of 
tubercular  matter.  Both  kidneys  were  affected  in  forty 
per  cent,  of  observed  cases,  in  the  remainder,  the  right 
and  left  kidney  were  attacked  with  about  equal  frequency, 
Eoberts  gives  the  right  kidney  as  affected  in  seven  cases, 
and  the  left  in  six ;  whilst  Meckel  declares  the  left  to  be 
more  frequently  attacked.  The  disease  rarely  causes 
great  enlargement  of  the  kidney,  when  this  is  the  case, 
it  is  due  to  obstruction  of  the  ureter,  and  the  consequent 


S36  DISEASES    OF    THE    KIDNEY. 

retention  of  the  caseous  and  purulent  fluid,  so  as  to  form 
pyo-nephrosis  ;  on  tlie  other  hand,  if  the  destruction  and 
removal  of  the  caseous  matter  is  rapid,  the  kidney  may 
be  only  slightly  enlarged,  or  may  even  be  somewhat  col- 
lapsed and  shrunk. 

113,  Treatment. — The  termination  of  these  cases  is 
usually  fatal,  either  by  the  exhaustion  caused  by  the 
original  disease  ;  more  frequently  by  secondary  tubercle  in 
other  organs.  Dr.  Eoberts  has  expressed  a  hope,  that  if 
the  tendency  toward  fresh  formation  of  caseous  material 
could  be  checked,  evacuation  of  the  deposit  already  formed 
in  the  kidney  might  occur,  as  is  sometimes  witnessed  in 
the  lungs,  and  quotes  a  case  of  Dr.  Bennett's,  in  support 
of  this  view.  In  a  case  under  my  care  a  few  years  ago,  of 
pyelitis  of  the  right  kidney,  followed  by  cystitis,  which 
existed  several  months,  the  urine  after  the  formation  and 
discharge  of  a  pelvic  abscess,  cleared  up,  and  presented 
nothing  abnormal ;  nor  had  there  been  recurrence  of  the 
urinary  affection,  when  he  consulted  me  a  few  years  sub- 
sequently for  an  affection  of  the  chest,  which  proved  tuber- 
cular. I  have  only  the  assumption  to  offer  that  the  case 
in  the  first  instance  was  due  to  scrofulous  inflamma- 
tion, having  no  opportunity  of  examining  the  kidney  post- 
mortem, but  the  whole  course  of  the  disease  indicated  it, 
whilst  he  passed  masses  closely  resembling  caseous  mate- 
rial during  the  progress  of  the  renal  affection.  Indeed 
it  was  only  the  fact  of  the  patient's  recovery  from  the 
attack  that  shook  my  belief  in  the  opinion  I  strongly  held 
from  the  first,  of  the  scrofulous  character  of  the  inflamma- 
tion. It  may  have  been  a  case  in  which  the  scrofulous 
material  was  discharged,  as  suggested  by  Dr.  Eoberts, 
from  the  arinary  passages,  whilst  the  inflammation  in  the 
pelvic  cellular  tissue,  may  have  arrested  further  deposit 
taking  place  in  the  kidney  or  bladder.      Such  a  termina- 


TUBERCULAE   INFILTEATION.  337 

tion,  liowever,  is  extremely  rare,  though  every  such  case 
encourages  us  to  hope  that  by  attention  to  the  treatment 
of  the  tuberculous  disease,  a  recovery  may  be  effected. 
This  is  best  effected  by  the  continued  administration  of  cod- 
liver  oil,  and  iodide  of  iron,  the  pyrexia  controlled  as  much 
as  possible  by  cold  sponging,  and  the  employment  of  food  as 
nutritious  and  digestible  as  possible,  whilst  any  diarrhoea 
that  may  arise  should  be  promptly  checked.  When  the  dis- 
ease is  limited  to  one  kidney,  and  there  is  as  yet  no  disease 
in  other  organs,  the  question  of  the  removal  of  the  affected 
organ  should  be  discussed.  Even  if  the  organ  is  not  re- 
moved, incision  into  the  inflamed  and  thickened  pelvis  is 
a  procedure  likely  to  afford  great  relief ;  and  lastly  when 
the  bladder  is  extensively  affected  cystotomy  should  be 
performed.  In  a  case  of  mine,  great  relief  was  given  by 
the  operation,  and  though  the  patient  ultimately  suc- 
cumbed, his  life  was  undoubtedly  prolonged  by  the  opera- 
tion. 


Tubercular  Infiltration. 

114.  Tubercle  may  be  deposited  in  the  kidney,  in  the 
general  tuberculosis  which  invades  many  organs  of  the 
body  simultaneously.  It  is,  however,  less  rarely  observed 
in  the  kidney,  when  only  one  organ  is  the  seat  of  the  pro- 
cess, than  in  the  lungs,  brain,  spleen,  etc.  The  tubercles 
are  scattered  throughout  the  kidney  substance,  being  most 
numerous  in  the  cortex,  they  appear  as  minute  yellowish 
granulations,  from  about  the  size  of  a  pin's  head,  to  small 
yellow  nodular  masses,  the  size  of  a  cherry-stone.  The 
kidney  tissue  appears  healthy,  except  that  round  the 
larger  deposits,  a  reddish  zone  of  congestion  may  be 
observed.      The  presence  of  tubercle  in  the  kidney  gives 

K 


338  DISEASES    OF    THE    EJDNEY. 

rise  to  no  symptoms.  If  tliere  is  much  pyrexia  there  may 
be  albuminuria,  but  that  depends  on  the  fever,  as  does 
also  the  concentrated  condition  of  urine.  Violent  lumbar 
pains  accompanied  by  severe  rigors,  occurring  in  patients 
ah'eady  the  subject  of  tubercular  disease,  may  lead  us  to 
infer  that  deposition  of  tubercle  is  occurring  in  the  kidney. 


CANCER. 


339 


CHAPTEE  VI. 

New  Growths  in  the  Kidney. 

Cancer. 

115.  Etiology. — Cancer  attacks  the  kidney  less  fre- 
quently than  any  other  organ  of  the  hody,  though  the 
statements  regarding  its  infrequency  are  perhaps  some- 
what exaggerated.  Cancer  of  the  kidney,  occurring  as  it 
does  at  the  extremes  of  life,  does  not  present  itself  so 
frequently  at  our  general  hospitals,  as  diseases  affecting 
the  kidneys  during  adolescence  and  middle  age.  It  is  met 
with  rather  in  the  hospitals  set  aside  for  the  treatment  of 
sick  children,  and  in  our  workhouse  infirmaries.  In  order 
therefore  to  obtain  a  definite  idea  of  the  frequency  of  renal 
cancer,  the  statistics  of  children's  hospitals,  and  workhouse 
infirmaries  should  be  incorporated  with  those  of  the  gen- 
eral hospitals.  In  the  following  remarks,  attention  will 
chiefly  be  drawn  to  primary  cancer  of  the  kidney,  which 
runs  a  definite  course,  attended  with  characteristic  symp- 
toms ;  whilst  secondary  cancer,  the  result  of  infection  from 
primary  cancer  elsewhere,  or  of  general  cancerous  mani- 
festations, and  which  is  rarely  attended  with  definite  clini- 
cal symptoms,  will  only  be  alluded  to  incidentally. 

Cancer  of  the  kidney  is  undoubtedly  more  frequent  in 
the  first  and  last  decades  of  life,  than  at  any  other  period. 
Out  of  123  collected  cases  of  primary  cancer  of  the  kidney, 
45  occurred  in  children  under  ten  ;  19  cases  in  persons 
between  fifty  and  sixty  ;  and  25  cases  between  sixty  and 
seventy ;  whilst  only  24  cases  are  noted  as  occurring  between 

z2 


340  DISEASES    OF    THE    KIDNEY. 

the  four  decades,  between  ten  and  fifty.  Contrary  to  the 
usual  experience  of  cancerous  disease,  renal  cancer  in 
adults  is  more  frequent  among  men  than  women.  It  is 
difficult  to  account  for  this,  for  though  men  may  be  more 
liable  to  blows  and  injuries,  still  it  might  be  thought  that 
pregnancy,  if  it  exercises  the  injurious  pressure  effect  on 
the  kidneys,  that  certain  writers  on  renal  disease  contend 
it  does,  would  place  the  sexes  on  a  level  in  this  respect. 
Dr.  Eoberts'  supposition  that  cancer  in  the  female  prefers 
the  generative  organs  to  the  kidneys,  may  therefore  be 
correct.  An  hereditary  predisposition  can  be  traced  in 
the  majority  of  cases,  especially  in  the  more  elderly,  in 
children  it  may  be  absent,  because  as  Sir  James  Paget 
has  pointed  out,  the  cancerous  tendency  has  not  yet 
declared  itself  in  the  parents  [Path.  Soc.  Trans.,  1874,  p. 
317).  Calculous  disease  of  the  kidney  may  induce  cancer 
of  that  organ,  since  post-mortem  we  often  find  renal  con- 
cretions in  cancerous  kidneys,  though  it  is  certainly  not 
such  a  frequent  clinical  sequel  as  in  the  case  with  biliary 
concretions.  A  good  clinical  instance  of  cancer  follow- 
ing calculus  is  given  by  Dr.  Norman  Moore  [Path.  Soc. 
Trans.,  1882),  and  also  by  Mr.  Pollard  in  the  Transactions 
for  the  current  year  1885.  Moveable  kidneys,  too,  not 
infrequently  become  the  seat  of  cancerous  deposit.  Blows 
and  injuries  are  often  referred  to  by  the  patients  as 
having  caused  the  disease.  In  some  cases  the  blow  seems 
to  have  rendered  the  disease — already  present,  but  latent 
— active.  In  others,  as  in  the  case  recorded  by  Dr. 
Brinton,  in  which  cancer  of  the  kidney  appeared  two 
years  after  a  blow  sufficiently  violent  to  cause  hsema- 
turia,  it  may  be  fairly  attributed  to  injury.  In  a  young 
sailor  who  died  in  my  ward  at  the  Seamen's  Hospital, 
from  primary  cancer  of  the  left  kidney,  no  deposit  being 
observed  in  any  other  organ,  the  only  possible  cause  that 


841 

CANCEB.  ^^^ 


could  be  assigned  was  a  strain  received  during  reefing, 
when  as  well  known  sailors  mainly  support  themselves  by 
pressing  the  belly  against  the  yardarm. 

116.  Symptoms.  —The  two  characteristic  symptoms,  tu- 
mour and  hematuria,  depend  as  regards  thek  prominence, 
mainly  on  the  age  of  the  patient,  the  nature  of  the  cancerous 
growth,  and  the  circumstances  favouring  its  development. 
The  earUest  symptom  is  often  the  hmiaturia.     It  may  be 
noticed  before  a  tumour  is  felt  in  the  loin,  or  pain  is  com- 
plained of.      On  the  other  hand  the  kidney  may  become 
much  enlarged  before  the  urine  becomes  bloody.     Accord- 
ing to  my  experience,  hematuria  usually  precedes  the 
detection  of  the   tumour  in  elderly   patients  ;    whilst  m 
children  the  presence  of  the  tumour  generally  first  draws 
attention  to  the  disease.     The  pain  may  be  very  severe, 
but  it  is  by  no  means  a  constant  symptom,  and  many 
cases  run  their  course  without  experiencmg  more  than 
sHght  discomfort  from  the  weight  of  the  tumour,  in  others 
severe  pain  may  be  followed  by  a  long  period  of  quiescence. 
The  tumour  usuaUy  presents  the  following  characters.     In 
its  growth  it  takes  the  path  of  least  resistance,  and  tends 
forwards  towards  the  navel,  making  its  way  upwards  to- 
wards the  hypochondrium,  and  downwards  towards  the 
pubes.     In  this  direction  it  meets  only  with  the  soft  and 
yielding  intestines,  instead  of  the  firm  lumbar  muscles  and 
fascia.      The  relation  of  the  tumour  to  the  intestmes 
depends  on  its  size.     If  small  the  natural  position  wiU  not 
be  much  interfered  with,  but  if  the  tumour  acquires  con- 
siderable dimensions,  then  the  relative  positions  become 
somewhat  altered.  If  the  right  Hdney  be  enlarged,  then  the 
coecum  and  lower  portion  of  the  ascending  colon  are  pushed 
back  to  the  outer  side  of  the  tumour,  whilst  the  upper  part 
of  the  ascending  colon  passes  somewhat  obhquely  in  fi-ont  of 
it,  the  duodenal  portion  of  the  smaU  intestine  being  pushed 


342 


DISEASES    OF    THE    KIDNEY. 


over  towards  tlie  navel.  On  the  left  side  the  descending 
colon  lies  -well  in  front  of  the  tumour,  though  if  the  en- 
largement be  great  it  will  be  compressed,  and  may  then 
only  be  felt  as  a  thick  cord  passing  somewhat  obliquely 
over  its  surface.  Owing  to  this  relationship  of  the  large 
intestine  to  the  anterior  surface  of  the  tumour,  a  tympani- 
tic note  can  generally  be  elicited  on  percussion  over 
some  portion  of  the  tumour ;  though  in  some  rare  cases 
this  may  be  absent,  owing  on  the  right  side  to  the  ascend- 
ing colon  being  entirely  pushed  downwards,  and  on  the 
left  to  the  descending  colon  being  so  stretched  and  com- 
pressed, that  on  percussion  it  does  not  yield  a  tympani- 
tic note.  In  this  last  case,  however,  it  can  be  usually 
felt  like  a  cord  obliquely  crossing  the  tumour.  In  some 
exceptional  cases,  the  large  intestines  are  found  altogether 
behind  the  tumour,  in  these  cases  growth  has  usually  been 
very  rapid. 

The  cancerous  tumour  feels  smooth,  rounded  and  elastic, 
somewhat  nodular,  and  irregularly  hardened  in  places.  It 
does  not  descend  on  deep  inspiration,  and  is  rarely  move- 
able. Their  elasticity  sometimes  leads  one  to  suspect 
fluctuation,  whilst  many  instances  of  pulsating  tumours 
have  been  recorded,  see  case  by  Mr.  T.  Holmes  {Path. 
Soc.  Trans.,  1873,  p.  149).  These  cases  may  be  mistaken 
for  aneurism.  The  largest  and  most  rapidly  increasing 
growths  usually  occur  in  children. 

Hccmaturia,  though  a  very  constant  symptom,  is  ab- 
sent in  about  one-half  the  cases  observed  (Eoberts, 
28  times  in  58  cases;  Ebstein,  24  times  in  50  cases). 
According  to  my  experience,  hematuria  is  more  fre- 
quently absent  in  children  than  in  adults.  In  elderly 
persons  hematuria  often  precedes  the  tumour.  Ke- 
peated  urinary  haemorrhage,  therefore,  in  old  persons 
accompanied  with  loss  of  flesh,  and  in  whose  bladder  on 


OAO 

CANCEB.  '^'"^ 


careful  examination  no_stone,  g^°7t>^^^,'^l,^'3f  .^^'°'^^ 


these  cases  there  may  be  no  pain  in  the  region  of  the  Lid- 
neys,  and  the  tumour  may  develop  but  slowly.  He- 
maturia when  present,  follows  no  constant  course.      It 

_         .  .1  T    _    _J ^-.-./^    +lTan    no    fl 


may  be  present  during  the  early  stage,  and  then  be  absent 
for  months,   returning  towards  the   end,  or  it  may  not 
occur  at  all  tiU  quite  the  later  stage  of  the  disease.    Unlike 
the  hematuria  caused  by  renal  calculus,  it  does  no   neces- 
sarily follow  upon  increased  movement  on  the  part  ot  tne 
patient,  nor  is  it  usually  accompanied  with  mcrease  _o. 
pam,  unless  a  clot  passes  down  the  ureter,  and  gives  rise 
to  colic      The  amount  varies  considerably,  and  though  not 
always  profuse  or  exhausting,  it  must  be  remembered  that 
no  disease  of  the  kidney  can  give  rise  to  such  a  pro  use 
hematuria  as  cancer;  especially  if  it  has  been  excited  by 
a  blow  or  injury  to  the  diseased  organ.  _ 

The   urine  in   cancer   of  the   kidney   is   generally  m- 
creased ;  it  may  be  diminished  by  temporary  obstruction  ot 
a  ureter  by  a  clot  of  coagulated  blood,  or  temporarily  ob- 
structed by  blockage  of  the  urethra  by  a  similar  cause,    it 
is  rarely  albuminous,  except  in  connection  with  the  hema- 
turia     When  albumin  is  constantly  present,  it  shows  that 
either  nephritis  or  waxy  degeneration  co-exists.     In  some 
rare  cases,  pus  has  been  observed  in  the  urme.    The  older 
writers  speak  of  the  presence  of  cancer  cells  m  the  urme, 
but  more  recent  investigations  have  proved  this  to  be  an 
error,  the  cells  observed  being  probably  the  caitdate  ce  s 
of  the  pelvis  of  the  kidney  much  swollen.      Cancer  cells 
might,  however,  appear  in  the  urine,  if  a  portion  oi  the 
growth  became   detached,   in   which   case    the    alveolar 
•structure  would  be  recognised  as  well.      Disturbances  of 
digestion  are  frequent  in  renal  cancer,  there  is  usuaUy 
nausea  and  loss  of  appetite.     In  rapidly  growmg  cancer. 


344  DISEASES    OF    THE    KIDNEY. 

however,  there  may  be  boulimia  and  thirst.  Owing  to 
compression  of  the  colon,  there  is  usually  constipation, 
but  diarrhoea  is  easily  provoked,  and  when  it  sets  in 
it  is  exceedingly  troublesome  to  deal  with.  Cancer  of 
the  kidney,  unless  there  be  some  complication,  does  not 
give  rise  to  pyrexia.  Eenal  cancer  runs  a  more  rapid 
course  in  children  than  in  adults.  In  the  former,  few 
cases  are  recorded,  extending  over  eighteen  months  from 
the  first  manifestation  of  the  disease  ;  in  the  latter,  life 
may  be  prolonged  for  three  or  four  years,  cases  giving  even 
a  longer  period  have  been  recorded.  In  forming  an 
opinion,  however,  as  to  the  probable  duration  of  life  in  any 
individual  case,  account  must  be  taken  of  the  degree  of 
cachexia  existing,  and  whether  other  organs  are  im^sli- 
cated. 

117.  Diagnosis. — A  cancerous  tumour  of  the  kidney 
may  be  taken  for  an  enlargement  of  some  other  organ  of  the 
abdomen.  The  rules  on  which  the  differential  diagnosis 
in  these  cases  is  based,  have  been  already  given  (p.  8). 
When  however,  cancer  of  the  kidney  co-exists  with  can- 
cerous enlargement  of  some  other  organ  of  the  abdomen, 
the  diagnosis  becomes  very  difficult,  if  not  in  some  cases 
impossible.  Thus,  in  cancer  of  the  right  kidney  with 
cancerous  deposits  in  the  liver  and  peritoneum,  or  of  the 
left  kidney  with  secondary  deposits  in  the  omentum. 
When  ascites  co-exists  with  renal  cancer,  the  difficulty  of 
diagnosis  is  undoubtedly  increased,  though  unless  the 
cancer  filfe  the  entire  cavity  of  the  abdomen,  there  ought 
to  be  no  hesitation  in  distinguishing  ascites  from  a  tumour 
of  the  kidney.  Enlarged  masses  of  lymphatic  glands  in 
young  children  may  be  taken  for  renal  cancer,  they,  how- 
ever, are  usually  to  be  found  on  both  sides  of  the  abdomen, 
whilst  renal  cancer  in  children  is  almost  invariably  uni- 
lateral.    Moreover,  a  careful  consideration  of  the  clinical 


CANCEE.  345 

conditions  ought  to  be  a  sufficient  indication  to  i^reveut  us 
mistaking  a  tabes  mesenterica  for  cancer  of  the  kidney. 
Other  renal  enlargements  may  be  taken  for  cancer,  such 
as  hydatids,  renal  cysts,  enlarged  moveable  kidney,  peri- 
nephritis, and  pyo-nephrosis.  In  the  former,  if  the  cyst 
has  opened  into  the  urinary  passages,  a  careful  and  syste- 
matic examination  will  detect  either  vesicles  or  booklets. 
If  the  cyst  be  intact,  the  more  elastic  feel,  fluctuation,  or 
fremitus  if  present,  the  absence  of  haematuria,  and  the  fact 
that  the  patient's  general  health  is  but  little  impaired, 
usually  enable  us  to  exclude  cancer.  If  is  often,  how- 
ever, a  matter  of  extreme  difficulty  to  distinguish  extensive 
and  rapidly  develoiDing  cystic  disease  of  the  kidney  from 
carcinoma,  if  the  growth  be  soft.  As  a  rule,  however, 
cancer  has  a  more  nodulated  surface,  and  on  manipulation, 
irregular,  hard  and  soft  patches  can  often  be  made  out, 
whilst  a  cystic  tumour  is  usually  more  elastic  than  a  can- 
cerous growth.  In  hydro-nephrosis  and  pyo-nephrosis,  the 
intermittent  discharge  of  watery  urine  or  pus,  generally  en- 
ables us  to  form  an  opinion.  Tumours,  too,  containing  fluid, 
are  usually  more  elastic,  fluctuate,  and  are  more  globular 
than  solid  ones,  moreover,  whilst  a  solid  tumour  usually 
makes  its  way  forwards,  towards  the  navel,  and  then 
spreads  equally  upwards  towards  the  hypochondrium,  and 
downwards  to  the  pelvis ;  the  usual  course  of  a  fluid 
tumour  is  to  extend  towards  the  navel,  and  then  more 
rapidly  upwards,  and  more  slowly  downwards.  An  en- 
larged, painful,  moveable  kidney  can  be  distinguished 
from  cancerous  growth  of  that  organ  by  its  greater  mova- 
bility,  and  the  want  of  distension  in  the  corresponding 
loin ;  whilst  if  the  moveable  kidney  has  acquired  adhe- 
sions, and  is  fixed  in  its  new  place,  then  the  latter  sign 
can  alone  be  reUed  on.  It  must  not  be  forgotten,  how- 
ever, that  moveable  kidneys  not  infrequently  become  the 
seat  of  cancerous  deposit. 


346  DISEASES    OF    THE    KIDNEY. 

118.  Morbid  Anatomy. — Primary  cancer  is  almost 
invariably  unilateral,  secondary  cancer  bilateral.  The 
frequency,  when  the  disease  is  unilateral,  with  which  the 
disease  affects  the  kidneys  is  a  matter  of  some  dispute. 
Ebstein  out  of  54  cases  found  the  right  affected  31,  and 
the  left  23  times  ;  Dr.  Eoberts  in  60  unilateral  cases 
found  each  kidney  affected  an  equal  number  of  times  ; 
whilst  Klebs  maintains  the  left  kidney  to  be  most  fre- 
quently attacked ;  and  Dickinson  found  11  belonging  to 
the  left,  and  only  one  to  the  right  kidney.  My  own  ex- 
perience is  in  accord  with  the  last  named  observer, 
indeed,  excepting  moveable  kidney  and  renal  calculus,  I 
have  found  in  all  diseases  of  the  kidney,  that  are  gene- 
rally unilateral,  a  preponderance  of  cases  in  which  the  left 
kidney  is  aifected. 

A  satisfactory  classification  of  malignant  growths  of  the 
kidney  has  still  to  be  made. 

Cancerous  growths  of  the  kidney  originate  either  in  the 
pelvis  of  the  kidney,  or  in  the  kidney  tissue  proper. 

1.  In  the  former  we  meet  with  the  ordinary  villous 
growth,  so  common  in  the  bladder,  and  which  is  regarded  as 
a  7Jrt2Ji7/o)n«,  whilst  formerly  it  was  classified  as  epithelioma. 
This  form  is  always  attended  with  profuse  haemorrhage. 
True  epithelioma  is  extremely  rare.  Dr.  Windle  forwarded 
to  the  Liverpool  Committee  of  the  British  Medical  Asso- 
ciation, who  reported  on  "  New  Growths  of  the  Urinary 
System,"  1883,  a  specimen  showing  some  squamous  evo- 
lution, with  shght  bird's  nest  formation ;  Eobin  and 
Eindfleisch  have  each  recorded  a  case.  Colloid  cancer 
springs  also  from  the  pelvic  mucous  membrane,  as  well 
as  from  the  substance  of  the  kidney.  At  Liverpool,  an 
excellent  specimen  from  Guy's  Hospital  was  exhibited  by 
Dr.  Goodhart. 

2.  The  cancerous  growths   of  the   kidney  proper  are 


CANCER.  347 

scirrhiis,  colloid,  and  encephaloid.  The  scirrhus  growths 
are  rare,  and  only  one  case  has  come  under  my  notice, 
it  was  found  post-mortem,  and  its  existence  was  not 
suspected  during  life,  as  there  was  neither  pain,  tu- 
mour or  hematuria,  the  patient  died  of  chronic  dysen- 
tery. The  left  kidney  was  affected,  a  portion  of  the 
organ  presented  a  hardened  yellowish-grey  appearance, 
cutting  with  a  fibrous  section,  yielding  httle  juice  on 
scraping,  and  the  whole  growth  intersected  by  numerous 
bands.  Colloid  cancer  of  the  kidney  apparently  arises  from 
dilatation,  and  the  infiltration  of  the  Mali^ighian  corpus- 
cles with  colloid  material.  It  is  rarely  distinct,  and  is 
usually  associated  with  other  growths,  especially  with 
medullary  cancer.  Encephaloid  or  medullary  cancer  is  by 
far  the  most  frequent  form  of  cancer  met  with  in  the  renal 
organs,  and  is  the  variety  that  runs  the  most  acute  course, 
and  also  attains  a  considerable  size.  Tumours  weighing 
25  to  30  lbs.  have  been  met  with,  even  in  young  children, 
but  these  very  large  tumours  are,  however,  generally  of  a 
mixed  character;  pure  encephaloid  growths  rarely  exceed- 
ing 12  to  15  lbs.  EncejDhaloid  cancer  varies  in  consist- 
ence, in  some  places  being  soft  and  semi-fluid,  in  others 
harder  portions  are  to  be  found  even  somewhat  resembling 
scirrhus  in  firmness.  The  irregular  softness  and  hard- 
ness often  give  to  the  tumour  a  feehng  of  fluctuation. 
It  sometimes  happens  that  one  part  of  the  tumour  deve- 
lopes  more  rapidly  than  another,  so  that  the  growth 
becomes  very  irregularly  shaped.  The  whole  of  the  kid- 
ney is  usually  involved,  but  if  only  a  portion  is  attacked, 
a  fine  hne  of  connective  tissue,  wiU  usually  be  observed 
dividing  the  renal  tissue  from  the  deposit.  The  secreting 
portion  thus  spared  is,  however,  rarely  quite  healthy,  the 
urinary  tubules  being  usually  enlarged  and  the  epithehum 
undergoing  granular  degeneration.     Owing  to  the  abund- 


348 


DISEASES    OF    THE    KIDNEY. 


ance  of  wide  tliin-walled  vessels,  often  showing  aneurismal 
dilatations  in  the  growth,  haemorrhage  is  of  frequent  oc- 
currence, so  that  these  tumours  have  been  called  "  fungus 
hffimatodes."  Secondary  deposits  in  other  organs,  especi- 
ally in  the  liver,  lungs  and  lumbar  glands  are  most  fre- 
quent with  encephaloid  cancer.  Mixed  cancerous  growths. 
The  most  frequent  is  a  mixture  of  encephaloid  with  sar- 
coma, Dr.  Dowse  [Path.  Sac.  Trans.,  1874)  has  recorded 
an  example  of  this  kind.  Schueppel  {o]}.  cit.)  describes 
a  kidney  weighing  28  lbs.,  which  showed  in  part  the 
characteristics  of  an  encephaloid  in  a  state  of  fatty 
degeneration,  and  in  part  those  of  an  alveolar  colloid 
carcinoma.  Fatty  cancer  (carcinoma  lipomatosum)  has 
been  described  by  Dr.  Hilton  Fagge  [Path.  Soc.  Trans., 
1876).  Under  the  microscope  in  the  fresh  state  the 
growth  showed  large  fatty  globules,  and  looked  as  if 
only  made  up  of  fat.  The  fat  globules,  however,  were 
really  contained  in  the  interior  of  cells  of  very  irregular 
form,  with  large  oval  nuclei.  Some  of  the  cells  were  quad- 
rilateral, some  pear-shaped,  and  in  some  the  form  of  the 
cells  was  cylindrical.  Hardened  with  chromic  acid,  the  sec- 
tion showed  a  portion  of  the  growth  to  be  composed  of  the 
characteristic  structure  of  a  carcinoma.  This  form  is 
extremely  rare,  the  only  other  description  is  by  Cornil  and 
iianvier  (carcinome  lijwmateux)  who  observed  it  in  two 
cases,  one  being  a  carcinoma  of  bone. 

Cancerous  growths  of  the  kidney  generally  form  adhesions 
with  the  surrounding  tissues,  and  so  become  firmly  fixed. 
They  may  extend  to  neighbouring  organs  and  compress  and 
even  perforate  the  intestines.  If  the  compression  of  the 
intestines  takes  place  rapidly  we  may  have  symptoms  of 
acute  obstruction.  Enlargement  of  the  right  kidney  has 
been  reported  as  having  caused  dilatation  of  the  stomach 
by  compression  of  the  duodenum  (Ebstein).      The  renal 


CANCER.  349 

vein  is  also  generally  involved,  and  in  this  way  the  growth 
may  reach  the  inferior  vena  cava  or  even  the  vena  azygos, 
portions  of  the  growth  are  thus  liable  to  be  carried  into 
the  circulation.  When  the  disease  originates  in  the  pelvis 
of  the  kidney  it  may  spread  to  the  renal  tissue,  and  vice 
versa. 

119.  Treatment. — The  treatment  can  be  only  pallia- 
tive, though  my  colleague,  Mr.  McCarthy,  recently  removed 
a  carcinomatous  kidney,  weighing  2  lbs.  5  oz.,  in  a  man  aged 
45.  The  operation  was  performed  on  March  18th,  and 
by  April  13th  the  wound  was  healed  and  the  patient  sitting 
up.  The  patient  must  be  placed  under  the  most  favour- 
able conditions  as  regards  food,  rest,  pure  air,  etc.  Pain, 
if  present,  relieved  by  morphia  injections.  The  hemat- 
uria is  best  controlled  by  gallic  acid,  given  in  ten  grain 
doses  every  four  hours  during  its  continuance,  and  if 
very  active  by  the  application  of  ice  in  a  bladder  to  the 
abdomen.  Ergot  combined  with  iron  may  be  employed  if 
there  is  repeated  haemorrhage  associated  with  great  pallor. 
The  tumour  if  large  should  be  prevented  from  dragging  as 
far  as  possible  by  the  careful  application  of  a  flannel 
roller  to  the  abdomen.  Constipation,  which  is  often  such 
a  distressing  complication,  must  be  overcome  with  the 
greatest  care,  since  purgatives  even  in  moderate  doses, 
often  excite  the  opposite  extreme,  and  lead  to  a  profuse 
diarrhoea  most  difficult  to  check.  Castor  oil,  colocynth, 
and  saline  purgatives,  had  best  be  avoided,  whilst  enemas 
aided  with  a  pill  composed  of  grey  powder  and  rhubarb, 
are  undoubtedly  the  safest,  and  as  an  effectual  means  as 
any  for  the  relief  of  this  form  of  constipation.  If  the 
clots  and  coagula  formed  by  the  hemorrhage  are  retained 
in  the  bladder,  they  must  be  removed  as  speedily  as  pos- 
sible by  gently  washing  out  the  bladder. 


350  DISEASES    OF    THE    KIDNEY. 


Miscellaneous  Growths. 

120.  Sarcoma. — Many  of  the  tumours  formerly  de- 
scribed as  cancerous,  would  now  undoubtedly  be  classified 
as  belonging  to  this  class  of  new  formations.  The  sar- 
comata are  tumours,  consisting  of  the  progressive  forma- 
tion of  connective  tissue,  which  retains  throughout  its 
growth  its  embryonic  state.  The  sarcomata  are  divided 
into  three  varieties,  according  to  the  form  of  the  cells, 
round,  spindle  or  fusiform,  and  myeloid.  According  to 
the  Liverpool  Eeport  on  new  growths  of  the  urinary 
organs  {Brit.  Med.  Jour.,  Jan.  12th,  1884),  these  growths 
have  been  classified  as  congenital  and  adult,  since  it  was  felt 
that  a  distinction  should  be  drawn  between  a  growth  distinct- 
ly the  result  of  a  developmental  error,  and  one,  which  aris- 
ing later  in  life,  might  have  a  different  source.  Congenital 
sarcomata  are  by  far  the  most  frequent,  as  may  be  imagined 
from  then'  typical  origin,  and  invariably  prove  fatal  during 
the  first  few  years  of  life.  They  are  encapsuled  growths, 
but  as  they  increase,  there  is  a  tendency  to  general  infil- 
tration. They  are  either  extra-renal,  spreading  from 
without,  generally  from  the  neighbourhood  of  the  hilus,  to 
the  substance  of  the  kidney,  or  sub-capsular,  originating 
immediately  beneath  the  capsule  of  the  kidney.  The 
extra-renal  variety  is  usually  round-celled,  and  both  kid- 
neys have,  in  the  majority  of  cases  recorded,  been  involved. 
Dr.  Abercrombie  has  recorded  three  examples  (Path. 
Soc.  Trans.,  1880),  of  sarcomatous  growtlis  invading 
both  kidneys  from  without ;  in  all  three  cases,  the  pelvis 
of  the  kidney  was  enlarged,  the  lining  membrane  being 
red  or  purplish,  whilst  without  near  the  hilus,  a  new 
growth,  mainly  composed  of  loose  connective  tissue,  with 
masses  of  small  round  cells,  interspersed  in  the  masses 


SAEC03IA.  351 

was  observed  pusliing  its  way  towards  the  kidney.  Tlie 
sub- capsular  growths  may  consist  of  round  or  spindle 
cells,  or  both  mixed.  Mr.  Paul,  in  the  report  already 
alluded  to,  thus  describes  a  specimen  of  his  own,  consisting 
of  two  kidneys,  weighing  twelve  ounces,  fi-om  a  seven 
months'  foetus.  Externally  they  appeared  quite  normal, 
and  when  the  capsules  were  stripped,  the  surface  was  kid- 
ney-coloured and  minutely  lobulated.  On  section,  the 
medullary  portion  of  each  was  made  up  of  lobules  of  white 
new  growth,  and  the  cortex  was  mottled  by  the  same ; 
but  there  remained,  at  least,  twenty  to  thirty  times  the 
normal  amount  of  renal  tissue.  Under  the  microscope, 
this  renal  tissue  was  more  embryonic  in  character  than 
that  of  a  foetus  of  full  time,  but  it  is  doubtful  whether 
it  is  the  correct  equivalent  for  a  seven  mouths'  foetus. 
The  lobules  of  white  growth  consisted  mostly  of  round 
cells,  but  in  many  parts  they  arranged  themselves  as 
though  attempting  some  higher  evolution.  The  same 
report  also  furnishes  an  account  from  Dr.  Osier  of 
Montreal,  of  a  specimen  taken  from  an  eight  months' 
foetus,  in  which  both  kidneys  were  equally  enlarged, 
and  which  like  the  preceding  case  has  been  classed 
as  an  adeno- sarcoma,  the  description  is  as  follows : — 
"  On  microscopical  examination  at  the  cortex,  the  tubuli 
uriniferi  and  Malpighian  bodies  were  easily  distinguished, 
but  separated  by  much  interlobular  tissue,  composed 
largely  of  spindle  cells.  Towards  the  pelvis,  the  entire 
substance  was  made  up  of  these  spindle  cells  closely  com- 
pressed together,  and  amongst  them  coils  of  epithelial 
cells,  some  resembhng  dilated  tubuH,  others  m-egularly 
shaped  Malpighian  capsules.  The  sections  showed  many 
irregular  small  and  large  spaces  (cysts)  through  the  enthe 
substance." 

Virchow  has  described  a  variety  of  very  small  round- 


352  DISEASES    OF    THE    KIDNEY. 

celled  sarcoma  (glioma)  as  springing  from  the  neurogKa 
of  the  nerves  of  the  kidney.  They  appear  as  small 
translucent  knots  in  the  cortical  part  of  the  kiduey. 

Myo- sarcomata  are  sarcomata  containing  muscular 
fibres  of  an  embryonic  character.  Of  the  recorded  cases 
that  have  come  under  my  notice,  the  disease  has  been 
unilateral  and  bilateral  in  an  equal  number.  The  case 
reported  by  Dr.  Dawson  Williams  [Path.  Soc.  Travis., 
1882,  p.  317)  may  be  taken  as  a  typical  example  of  this 
kind  of  growth,  and  will  serve  best  for  a  general  descrip- 
tion. The  tumour,  together  with  the  left  kidney,  the 
ureters,  and  the  bladder,  were  removed  en  masse.  Section 
of  the  tumour  revealed  a  smooth,  indistinctly  lobulated 
surface,  of  a  general  yellowish-white  hue,  but  with  pinkish 
mottlings ;  the  consistency  was  everywhere  soft,  and 
towards  the  upper  part  the  substance  was  almost  diffluent, 
so  that  after  the  specimen  had  been  washed  a  ragged- 
walled  cavity  was  left.  The  right  ureter  could  be  traced 
into  the  tumour,  and  a  director  passed  along  it  led  into 
the  mass.  No  vestige  of  the  natural  kidney  substance 
could  be  distinguished  by  the  naked  eye.  The  tumour 
weighed  1  lb.  13^  oz.,  equivalent  to  about  one-sixth  of  the 
total  body  weight.  Sections  made  through  portions  of  the 
tumour  taken  from  various  parts  and  hardened  in  bichro- 
mate of  potash  showed  an  unusual  structure.  The  greater 
part  of  each  field  was  occupied  by  fibrillated  bundles  ;  these 
bundles  were  made  up  of  cylindrical  fibres,  having  a 
direction  generally  parallel  to  each  other,  but  the  bundles 
were  arranged  in  the  most  diverse  planes,  crossing  and 
intersecting  one  another  at  every  angle  ;  tracts  of  small- 
celled  tissue,  chiefly  of  the  spindle-shaped  variety,  were 
also  encountered,  as  well  as  sections  of  the  kidney  tubules, 
and  in  one  or  two  instances  masses  which  were  regarded 
as  altered  Malpigliian  bodies.      Being  at  a  loss  to  under- 


MELANOTIC    SARCOMA.  353 

stand  the  nature  of  this  fibrillated  structure,  some  of  the 
sections  were  submitted  to  Dr.  Klein,  and  he  immediately 
expressed  his  opinion  that  they  were  composed  of  muscular 
fibres  of  the  voluntary  type.  Mr.  Frederick  Eve's  ac- 
count of  specimens  of  tumours,  composed  of  stripped 
muscle  and  sarcoma  tissue  from  the  kidneys,  in  the  same 
volume  of  the  PatJwloyical  Transactions  (1882),  gives  an 
excellent  description  of  the  general  characters  presented 
by  these  tumours. 

Melanotic  Sarcoma. — These  growths  no  doubt  from  their 
high  degree  of  malignancy  were  formerly  regarded  as  car- 
cinomatous, there  is  now,  however,  but  little  doubt  that 
the  majority  of  specimens,  if  not  all  of  them,  are  sarcoma- 
tous. The  prevailing  character  is  the  spindle-shaped  cell, 
though  round  or  oval  cells  may  be  present,  the  pigment, 
melanin,  is  deposited  within  the  cells.  This  pigment  at 
first  has  a  brownish  colour,  but  rapidly  acquires  an  inky 
blackness  on  exposure  to  air.  The  pigmentation  is  gen- 
erally very  unequally  distributed.  Melanotic  sarcoma  of 
the  kidney  in  adults  is  usually  secondary  to  deposits  in 
other  organs,  in  children  it  may  occur  as  a  primary  affec- 
tion and  then  is  congenital. 

121.  Adenoma. — Adenoma  of  the  kidney,  owing  to 
the  smallness  of  the  growth,  may  escape  observation,  and 
this  has  probably  given  rise  to  an  idea  that  they  are  rare. 
In  the  report  [Brit.  Med.  Jour.,  Jan.  12th,  1884)  already 
referred  to,  two  varieties  are  recognised,  the  one  tubular, 
the  other  intra-cystic.  The  former  consists  of  tubes,  much 
hke  convoluted  renal  tubes,  but  larger,  and  containing 
more  epithehal  cells  ;  the  latter  has  a  villous  appearance, 
the  stalks  being  clothed  with  a  single  layer  of  cubical 
epithelium.  They  are  almost  invariably  bilateral,  and 
generally  multiple,  and  rarely  exceed  the  size  of  a  pea. 
Many  new  growths  of  the  kidney,  however,  are  accom- 

AA 


354  DISEASES    OF    THE    KIDNEY. 

panied  by  an  increase  of  the  gland  tissue,  and  an  adeno- 
matous appearance  is  given  them,  thus  we  may  have  an 
adeno- sarcoma,  adeno-myxoma,  adeno- carcinoma,  etc. 

122.  Lymphadenoma  of  the  kidney  occurs  as  part  of 
the  general  disorder,  deposits  of  a  similar  nature  being 
found  in  the  lymphatic  glands  elsewhere.  The  deposit 
which  is  of  a  yellowish-white  colour  is  distributed  through 
the  kidney,  especially  in  the  cortex,  and  occurs  in  irregu- 
larly ovoid  masses,  from  the'  size  of  a  mustard  seed  to 
that  of  a  bean.  They  consist  of  a  fibrous  net-work, 
blended  with  the  interstitial  tissue,  in  which  are  dispersed 
numerous  lymph  corpuscles,  some  of  these  are  granu- 
lar and  contain  no  nucleus,  others,  larger,  are  multi-, 
nuclear.  A  very  good  description  of  this  affection  is 
given  by  Dr.  Coupland  {Path.  Soc.  Trans.,  vol.  xxviii.). 
Leucamic  growths. — The  deposits  consist  of  an  accumu- 
lation of  white  corpuscles  and  a  delicate  net-work  of 
lymphoid  tissue,  distending  and  enlarging  the  blood- 
vessels, giving  rise  to  small  marrow-like  masses,  varying 
in  size  from  a  poppy  seed  to  that  of  a  hazel  nut.  They 
are  also  part  of  the  general  disorder,  and  when  met  with 
in  the  kidney  are  found  as  well  in  the  spleen  and  liver. 

123.  Iiobulated  Fatty  growths,  apparently  originat- 
ing from  the  capsule  of  the  kidney,  are  occasionally  met  with. 
They  have  been  mistaken  for  multiple  supra- renal  capsules. 
The  whole  organ  may  be  transformed  into  a  fatty  mass, 
or  only  a  portion.  In  the  majority  of  instances  some 
other  lesion  exists,  generally  of  a  calculous  nature.  A 
case  of  this  kind  is  reported  by  Dr.  H.  Browne  {Path.  Soc. 
Trans.,  vol.  xii.,  p.  132),  by  Dr.  Whipham  (Path.  Soc. 
Trans.,  vol.  xix.),  and  by  Dr.  Eickards  {Brit.  Med.  Jour., 
July  7th,  1883)  ;  whilst  in  Mr.  Heath's  case  {Path.  Soc. 
Trans.,  vol.  x.)  the  renal  artery  was  obliterated.  Fatty 
growths  may  also  arise  from  the  pelvis  of  the   kidney. 


FIBRO-FATTY    GROWTHS.  355 

Extra-renal  fatty  tumours,  springing  from  the  outside  of 
the  capsule,  or  originating  from  the  adipose  cellular  tissue 
surrounding  the  kidney  are  by  no  means  infrequent ;  in 
most  of  the  cases  the  organ  is  atrophied  by  the  pressure. 
These  fatty  growths  of  the  kidney,  which  are  compara- 
tively common,  must  not  be  confounded  with  that  ex- 
tremely rare  affection  we  have  already  spoken  of  (p.  348), 
carcinomatous  Hpoma. 

Fibroid  tumours  are  occasionally  met  with,  either  as 
small  fibromata,  in  the  form  of  small  nodules  composed 
of  dense  fibrous  tissue  in  which  may  be  found  atrophied 
urinary  tubules  ;  or  as  large  fibro- cartilaginous  growths, 
which  evidently  originate  from  the  fibrous  tissue  of  the 
capsule,  and  by  their  growth,  gradually  destroy  the  renal 
tissue.  Some  of  these  tumours,  which  may  attain  the  size 
of  a  cocoa-nut,  have  a  somewhat  cystic  appearance,  caused 
by  the  distension  of  the  pelvis  of  the  kidney. 


aa2 


356  DISEASES    OF    THE    KIDNEY. 


CHAPTEE  VII. 

PaBASITES    in    THE    EjDNEY. 

Hydatids. 

124.  Etiology.  —  Echinococci  cysts  are  about  five 
times  less  frequent  in  the  kidney  than  in  the  liver.  As 
regards  the  lungs,  an  equal  frequency  subsists ;  whilst 
with  respect  to  the  other  organs  and  tissues,  the  kidney 
is  more  often  the  seat  of  the  disease.  The  tendency  to. 
the  disease  is  very  marked  in  some  countries,  as  in  Ice- 
laud,  South  Australia,  and  in  some  parts  of  Germany  and 
Silesia.  In  these  countries  the  disease  seems  to  be  trans- 
mitted by  means  of  dogs,  who  harbour  the  taenia  echino- 
cocci in  considerable  numbers.  In  Iceland  and  South 
Australia  the  agricultural  class  hve  in  close  contact  with 
their  dogs,  whilst  in  Silesia  it  is  probable  that  the  disease 
may  be  actually  communicated  by  eating  dog's  flesh,  a 
practice  often  resorted  to  by  the  poorer  classes.  It  is 
said  that  the  disease  is  more  frequent  in  man  than  in 
woman,  but  discordant  statements  have  been  made  with 
regard  to  this  point.  In  Iceland  it  is  said  that  every 
seventh  person  dies  of  hydatid  disease  of  some  organ  or 
other.  When  the  kidneys  are  attacked,  the  disease  is 
usually  unilateral,  the  left  kidney  being  the  one  most  fre- 
quently affected. 

125.  Symptoms. — Unless  the  cyst  ruptures  at  an 
early  date  a  tumour  will  slowly  form  ;  this  may  attain  the 
size  of  an  orange  or  cocoa-nut.     It  presents  the  character- 


HYDATIDS.  357 

istic  relations  of  renal  tumours  generally  (p.  8),  and  by 
this  means  it  can  be  distinguished  from  enlargements  of 
other  organs.  It .  is  usually  more  rounded  than  other 
tumours  of  the  kidney,  often  fluctuates  obscurely,  rarely 
distinctly,  whilst  fluctuation  is  sometimes  absent.  Occa- 
sionally the  so-called  "hydatid  fremitus"  can  be  made 
out,  and  when  present  it  is  a  distinctive  sign.  To  elicit 
it,  the  fingers  of  one  hand  are  to  be  laid  on  one  side  of  the 
tumour,  whilst  a  sharp  percussion  stroke  is  given  with  two 
fingers  of  the  other  hand  to  the  opposite  side  of  the 
tumour.  The  fremitus  may  also  be  distinguished  by  the 
stethoscope  when  the  tumour  is  sharply  struck.  It  is  said 
that  the  note  is  only  obtained  when  the  cyst  contains 
many  vesicles,  but  is  often  absent  even  in  this  condition. 
If  any  doubt  exist  as  to  the  nature  of  the  contents  it  can  be 
solved  by  the  introduction  of  the  aspirating  needle  and  the 
examination  of  the  fluid  withdrawn.  This  is  clear,  usually 
alkaline,  sometimes  neutral,  never  acid,  nor  urinous. 
The  specific  gravity  is  about  1*009,  never  below  1*006 
(Bartels) ;  never  contains  albumin  unless  the  cyst  has 
become  inflamed ;  hooklets  and  vesicles  are  generally  to 
be  found  in  the  fluid,  but  may  be  absent. 

When  the  tumour  bursts  and  discharges  into  the  urin- 
ary passages,  the  contents  are  evacuated  by  the  urine. 
In  the  majority  of  cases,  vesicles  and  hooklets  will  be 
passed,  in  others  only  an  opalescent  looking  fluid  in 
which  a  few  scattered  hooklets  will  be  observed  on  care- 
fully examining  the  deposit.  The  passage  of  the  vesicles 
occurs  at  irregular  intervals,  and  usually  occasions  much 
pain,  whilst  the  urine  for  the  time  often  becomes  bloody 
and  purulent,  in  fact  giving  rise  to  all  the  symptoms  of 
renal  coHc.  The  vesicles  may  be  sufficiently  numerous  to 
block  the  urethra,  and  so  give  rise  to  retention  of  urine ; 
or  a  vesicle  may  become  impacted  in  the  ureter  and  so 


358  DISEASES    OF    THE    KIDNEY. 

cause  for  a  time  a  condition  of  hydro-nephrosis.  After  a 
discharge  of  vesicles  the  tumour  usually  diminishes,  un- 
less the  above  accident  happens,  and  recovery  may  take 
place  at  once,  or  after  a  few  more  discharges.  In  some 
rare  cases  a  fresh  discharge  has  occurred  after  the  lapse 
of  two  or  three  years,  probably  due  to  a  secondary  forma- 
tion. Sometimes,  however,  the  cyst  suppurates  and  this 
condition  is  attended  with  fever,  which  is  always  absent  in 
uncomphcated  cases.  Eupture  of  the  cyst  often  occurs 
suddenly,  after  a  blow,  a  strain,  or  prolonged  exertion. 
Sometimes  it  is  preceded  for  some  days,  by  an  increase  of 
pain,  and  discharge  of  blood.  The  duration  of  the  dis- 
ease is  very  variable,  but  it  usually  runs  a  favourable 
course,  far  more  so  than  in  other  organs.  About  fifty  per 
cent,  of  the  cases  recover,  after  spontaneous  discharge  of 
the  contents  of  the  cyst  by  the  urinary  passages.  About 
twenty- six  per  cent,  recover  after  tapping  or  other  surgical 
operations ;  whilst  about  thirteen  per  cent,  of  the  cases 
are  fatal.  These  are  caused  either  by  the  suppuration  of 
the  sac,  the  most  frequent  cause  of  death  ;  or  by  rupture 
of  the  cyst  internally  into  the  abdomen  or  cavity  of  the 
thorax.  In  some  rare  cases  calcification  of  the  cyst  may 
occur.  Lastly,  in  about  eleven  per  cent,  of  the  cases  no 
statement  is  made  with  regard  to  the  ultimate  issue.  Dr. 
Eoberts  records  a  unique  case,  comprising  a  series  of  mis- 
adventures— the  patient  had  only  one  kidney,  that  kidney 
became  the  seat  of  an  hydatid  cyst,  the  cyst  burst  and 
was  discharging  itself  through  the  pelvis  of  the  kidney, 
when  unfortunately  a  calculus  blocked  the  way  and  pre- 
vented the  vesicles  from  passing,  fatal  retention  of  urine 
ensuing  in  consequence. 

126.  Diagnosis. — Hydro-nephrosis  is  the  disease  of 
the  kidney  most  commonly  taken  for  a  renal  hydatid  cyst. 
The  previous  history  of  the  case,  in  the  majority  of  in- 


HYDATIDS,  359 

stances,  will  enable  us  to  distingtiisli  between  the  two 
affections,  otherwise  in  the  absence  of  distinct  "  hydatid 
fremitus  "  a  differential  diagnosis  cannot  be  made  without 
withdrawing  some  of  the  contents  of  the  tumour,  when  an 
analysis  of  the  fluid  (p.  321)  will  declare  its  nature. 
Hydatid  tumour  of  the  kidney  is  distinguished  from  other 
enlargements  of  the  abdominal  and  pelvic  viscera  by  the 
same  principles  as  regulate  the  diagnosis  of  all  renal  en- 
largements (p.  8).  It  may  be  taken  for  an  ovarian 
tumour,  especially  when  the  hydatid  tumour  developes 
downwards  into  the  pelvis.  By  bearing  in  mind,  however, 
the  relation  of  the  bowel  to  the  anterior  surface  of  the  tu- 
mour, and  by  an  examination  by  the  rectum,  and  also  by 
compression  of  the  ureters,  this  error  ought  to  be  avoided. 

The  discharge  of  echinococcus  vesicles  and  booklets 
(figs.  31,  82,  33)  into  the  urine,  especially  if  a  well-defined 
renal  tumour  is  present,  and  the  discharge  is  attended 
with  symptoms  of  renal  colic,  is  an  undoubted  proof  of  the 
existence  of  hydatid  disease  of  the  kidney.  In  some  rare 
cases,  however,  hydatids  of  the  abdominal  viscera  may 
open  into  the  urinary  passage,  and  discharge  booklets  and 
vesicles,  without  there  being  hydatid  disease  in  the  kidney. 
According  to  Murchison,  however,  no  case  of  hydatid 
tumour  of  the  liver,  has  ever  taken  this  direction. 

127.  Morbid  Anatomy. — The  parasite,  that  gives 
rise  to  echinococci  cysts,  is  a  small  tri-segmented  cestoid 
worm  (tcBnia  echinococcus),  which  infests  the  intestines  of 
dogs  and  wolves.  They  do  not  exceed  a  quarter  of  an  inch 
in  length,  and  the  last  joint  alone  contains  ova.  These 
ova  received  into  the  intestines  develop  embryos,  which 
at  the  time  of  emergence  from  the  egg,  are  minute  ovoid 
bodies,  about  the  size  of  the  red  corpuscle  of  the  frog's 
blood.  The  embryo  penetrates  the  tissues  and  organs,  and 
forms  cysts.     This  cyst  when  developed  consists  of  a  firm 


360 


DISEASES    OF    THE    KIDNEY. 


fibrous  capsule,  about  -^  inch,  thick,  intimately  connected 
with  the  tissue  of  the  organ,  and  highly  vascular.  With- 
in this  is  a  jelly-like  translucent  membrane,  of  laminated 
hyaline  structure — this  is  the  so-called  "  mother  vesicle." 
This  membrane  apparently  consists  of  a  body  yielding 
collagen,  for  on  boiling,  a  peptone-like  body  is  formed  and 
which  has  a  sHght  reducing  action  on  alkaline  solutions 
of  cupric  sulphate.  This  sac  holds  the  clear  limpid 
fluid,  and  unless  the  cyst  is  barren  contains  numerous 
"  daughter  vesicles,"  these  develop  from  the  walls  of  the 
mother  cyst  but  soon  separate,  so  that  in  examining  the  con- 
tents of  an  hydatid  tumour  we  meet  with  some  vesicles  still 
attached  (fig.  30,  No.  1 ),  whilst  others  are  found  floating  free 


Pig.  30. — Hydatid  found  in  man.  1.  A  fragment  of  the  natural  size; 
at  its  edges  are  shown  the  layers  of  which  it  is  composed ;  on  the  exter- 
nal surface  are  several  hydatid  germs  of  different  periods  of  development. 
2.  One  of  the  germs  flattened  and  magnified  forty  times,  showing  the 
stratified  layers. 

(figs.  31,  32).  Some  of  these  daughters  attain  a  consider- 
able size,  they  may  range  from  a  pin's  head  to  a  goose's 
egg;  the  largest,  however,  contain  smaller  vesicles  and  these 
again  others,  so  that  one   sac  may  contain   four  genera- 


HYDATIDS. 


361 


tions.  These  vesicles  being  discliarged  from  the  body  either 
of  man  or  cattle,  for  oxen  and  especially  ehee]p  are  subject 
to  hydatid  disease  as  well  as  man,  find  their  way  into  the 
intestines   of    the   dog,   usually  by   eating    the   offal   of 


Fig.  31. — EcMnococci  or  "  daughter  vesicles  "  from  a  hydatid  tumour. 
The  one  (a)  has  the  head  retracted  within  the  vesicle  j  the  other  (6)  has 
the  head  extruded. 


Fig.  32.  — (A.)  An  E cMnococcus  riewei  transversely,  the  head  being 
directed  towards  the  observer ;  s,  s,  suctorial  discs. 


slaughtered  cattle,  and  there  develop  into  the  fully 
formed  taenia.  The  proglottis  or  terminal  segment  which 
alone  contains  the  ova,  is  discharged  from  their  intestines 
this  finds  its  way  to  the  food  of  man,  or  on  to  the  herbage 
in  the  case  of  cattle,  again  passes  through  the  encysted 
state  as  a  hydatid  and  so  the  circuit  is  constantly  being 
renewed. 


362 


DISEASES    OF    THE    KIDNEY. 


128.  Treatment. — When  the  cyst  has  ruptured,  and 
the  vesicles  are  being  freely  discharged  from  the  bladder, 
there  remains  little  for  us  to  do  but  to  watch  the  progress 
of  the  case.  The  abdomen  should  be  firmly  bandaged, 
and  gentle  friction  employed  over  the  tumour  to  aid  their 
escape.      The   patient  should  be  warned  against  undue 


Fig.  33. — (B.)  The  circle  of  hooklets  seen  upon  its  under  surface; 
thirty-four  in  number,  seventeen  long  and  seventeen  short.  (C.)  b,  c. 
Lateral  views  of  the  separate  hooklets — b,  the  base ;  c,  the  central  ex- 
tremity or  bifid  process  of  the  base  ;  e,  hooklets  viewed  upon  the  concave 
or  inferior  border ;  /,  g,  h,  a  diagram  illustrating  the  movements  and 
position  of  the  hooklets. 

exertion,  or  engaging  himself  in  any  occupation,  likely  to 
cause  strain  during  their  discharge,  in  case  suppurative 
action  be  excited,  or  even  rupture  of  the  discharging  cyst 
caused.  As  diuretics  have  been  found  to  assist  the  dis- 
charge of  the  vesicles,  these  remedies  may  be  administered, 
and  if  there  is  much  pain  from  colic  during  their  passage 
sedatives  should  be  combined  with  them,  indeed  a  small 


HYDATIDS.  363 

quantity  of  opium,  by  relieving  spasm,  not  only  soothes  the 
the  irritation,  but  facilitates  their  discharge.  When  the 
cyst  is  intact,  or  if  after  it  has  burst,  the  escape  of  the 
vesicles  is  prevented  either  by  the  presence  of  a  renal 
calculus,  or  impaction  of  the  vesicles  themselves  in  the 
ureter,  the  contents  should  be  evacuated  without  delay. 
For  though  the  chance  of  the  cyst  ultimately  bursting  into 
the  urinary  passages,  and  thus  effecting  a  spontaneous 
cure  is  very  great,  still  it  is  not  fair  to  expose  the  patient 
to  the  chance  of  rupture  in  some  untoward  direction,  and 
which  may  be  unexpectedly  occasioned  by  some  unlooked  for 
accident.  It  is  generally  sufficient  to  tap  the  tumour  in  the 
positions  indicated  at  p.  823,  with  a  large  aspirator  needle, 
and  then  to  evacuate  the  contents.  If  there  be  many  large 
"  daughter  vesicles  "  containing  other  daughter  vesicles 
these  may  not  escape,  but  usually  puncture  of  the  mother 
cyst  is  followed  by  their  death  and  absorption.  Galvano- 
puncture  has  been  advised  and  many  successful  cases 
published,  but  it  presents  no  advantages  over  aspiration, 
and  if  by  chance  the  needles  are  not  sufficiently  insulated, 
suppuration  may  be  excited.  Should  the  sac  become  in- 
flammed  and  suppurate  recourse  must  be  had  to  free  in- 
cision and  drainage  tubes. 

To  prevent  the  extension  of  the  disease  in  districts  where 
it  has  become  rife,  the  following  rules  laid  down  by  Mur- 
chison  should  be  followed. 

a.  To  prevent  dogs  feeding  on  the  offal  of  sheep  and  of 
other  animals  infested  with  hydatids.  Dogs  ought  to  be 
rigidly  excluded  from  all  slaughter-houses  or  knackeries,, 
and  "  dog's  meat"  ought  always  to  be  thoroughly  boiled. 

h.  To  destroy,  as  far  as  possible,  the  tape-worms  gene- 
rated in  the  dog,  for  which  purpose  it  would  be  well  that 
all  dogs  were  periodically  physicked,  and  theii-  excreta 
buried  in  the  ground  or  burnt. 


364  DISEASES    OF    THE    KIDNEY. 

Vermifuge  medicines  have,  however,  but  little  effect; 
but  it  is  said,  aUowing  cattle  the  free  use  of  rock  salt  is 
prophylatic  and  powerfully  checks  the  extension  of  the 
disease  among  flocks.  It  probably  acts  on  the  newly  in- 
troduced ova,  by  hardening  their  envelopes,  just  in  the 
same  way  that  injections  of  common  salt  destroy  thread- 
worms in  the  lower  bowel. 


BiLHAEZIA    H^MATOBIA    (EnDEMIC    H^EMATUKIa). 

129.  Etiology.  —  The  Distoma  Haematobium,  now 
named  Bilharzia,  in  honour  of  its  discoverer  Bilharz, 
was  first  found  in  the  urinary  passages  of  some  Egyp- 
tians, whose  diseases  Grriesinger  was  investigating.  So 
common  is  it  in  that  country,  that  Griesinger  found  it  to 
exist  in  32  per  cent,  of  all  the  post-mortems  he  made. 
Since  then  it  has  been  found  to  be  prevalent  among  the 
residents  of  the  Cape  of  Good  Hope,  South-East  Africa, 
the  Mauritius  and  in  some  other  hot  countries.  Owing 
to  our  increased  intercourse  with  these  countries,  and 
the  tendency  of  Europeans  to  return  home  when  in- 
valided, instances  of  this  disease  in  England  are  by  no 
means  infrequent.  Besides  inhabiting  the  urinary  organs, 
especially  the  bladder  and  prostate,  it  is  also  found  in  the 
intestines  and  portal  veins. 

The  Haematobium  is  a  smaU  trematode  bisexual  entozoon. 
The  male,  which  rarely  exceeds  i  inch  in  length,  is  shorter 
and  broader  than  the  female  which  is  more  filiform,  and 
may  attain  to  nearly  f  inch.  They  bear  two  suckers. 
The  male  possesses  a  long  canal  in  its  upper  half  in  which 
the  female  is  partially  inserted  during  copulation.  The 
ova,  which  are  diagnostic  of  the  disease,  are  oval  shaped, 
being  about   ^^  inch  long  and  -^J^j  inch  in  width,  and 


BILHAKZIA    HiEMATOBIA. 


365 


prolonged  into  a  peak  or  spine  at  the  anterior  end  of  the 
capsule ;  according  to  Dr.  Zincarol  {Path.  Soc.  Trans.,  1882) 
the  ova  from  the  intestines  have  a  lateral  instead  of  an  an- 


FiG.  34. — Eipe  egg  containing  embryo  (Harley). 

terior  spine.     The  enclosed  embryo  (fig.  34)  escapes  by  a 
kind  of  dehiscence,  and  at  once  commences  very  active 


Fig.  35. — "Various  forms  assumed  by  ciliated  embryo  (Harley). 


rotatory   and  vermicular    movements,  assuming   various 
shapes    (fig.    35)   cylindrical,    elliptical,   flask-shape,   etc. 


366 


DISEASES    OF    THE    KIDNEY. 


Dr.  J.  Harley,  who  has  succeeded  in  hatching  the  embryos 
from  eggs,  observed  that  after  swimming  actively  about 
for  two  or  three  hours  the  motions  gradually  ceased  and 
the  animal  died,  and  that  after  death  the  cilia  were  rarely 
visible.  It  is  a  question  whether  the  parasite  reaches  the 
body  by  the  skin,  by  the  mouth,  or  by  the  urethra. 
Dr.  Harley  is  in  favour  of  the  first  two  suppositions, 
and  thinks  that  a  minute  leech-like  animal  fixes  itself 
on  the  skin  of  a  bather,  and  by  means  of  an  ovipositor 
implants  the  ova  in  a  superficial  vein,  during  the  hatch- 
ing process,  the  irritation  attending  the  fQOvements  of  the 
free  embryos  would  result  in  an  indolent  form  of  ulcera- 
tion, and  the  little  animals  would  be  carried  by  the  cir- 
culation from  the  ankle  to  the  pelvis.  As  a  matter  of 
fact,  residents  in  South  Africa,  during  the  first  year  or 
two,  are  liable  to  be  attacked  with  large  indolent  sores, 
leaving  .scars  like  syphilitic  ulcers.  This  applies  to  the 
rural  population  who  are  obliged  to  use  river  water,  or 
water  from  pools  and  marshes  ;  the  townspeople  who  use 
stored  rain  or  well  water  being  rarely  affected  by  the  disease. 
If  such  a  mode  of  infection  be  possible,  it  may  be  assumed. 
Dr.  Harley  thinks,  that  it  would  be  still  more  easily  affected 
by  the  passage  of  the  animal  or  its  eggs  to  the  mucous 
membrane  of  the  stomach  and  rectum  directly  by  the 
mouth;  whilst  Bilharz  has  associated  the  similar  parasitic 
disease  of  the  intestinal  veins  and  dysentery  in  a  manner 
that  implies  cause  and  effect.  With  regard  to  its  entrance 
into  the  body  through  the  urethra,  Dr.  Harley  observes 
that  a  female  appears  to  be  incapable  of  receiving  the 
disease  from  an  infected  male,  nor  has  Dr.  Harley  ever 
observed  the  liberation  of  a  living  embryo  from  the  egg, 
when  immersed  in  urine,  or  even  an  active  living  embryo. 
It  is  therefore  probable  that  the  propagation  of  the  parasite 
takes  place  in  the  mucus  of  the  urinary  passages,  and  that 


BILHABZIA    H^MATOBIA.  367 

the  ova  wliicli  escape  into  the  urine  are  retarded  in  their 
development,  and  ultimately  perish. 

130.  Symptoms. — The  parasite  invades  the  intestines 
and  the  branches  of  the  portal  system,  where  it  gives  rise 
to  a  peculiar  form  of  dysentery  ;  also  the  mucous  surface 
and  minute  vessels  of  the  bladder,  ureter,  and  kidney. 
The  mischief  occasioned  in  the  genito- urinary  organs  is, 
however,  far  greater  than  when  the  intestinal  tract  alone 
is  affected.  The  urine  in  these  cases  has  been  thus  de- 
scribed by  Harley.  Pale  amber  coloured,  sp.  gr.  1-017, 
depositing  a  layer  of  dirtyish- white  flocculent  matter,  con- 
taining short  filaments  of  Jg- of  an  inch  in  diameter,  of 
brownish  colour  and  soft  consistence,  shorter  and  wider 
fragments  of  the  same  substance,  a  little  reddish  mass 
like  a  little  clot  of  blood,  and  numerous  white  specks. 
This  deposit,  examined  microscopically,  contained  pus 
corpuscles;  and  the  filamentous  bodies  contained,  im- 
bedded in  them,  great  numbers  of  bright  highly  refrac- 
tive bodies,  which  were  identified  as  the  ova  of  the 
Bilharzia.  The  urine  also  generally  contains  traces  of 
albumin,  uric  acid,  urates,  and  oxalate  of  lime.  In  addi- 
tion to  the  reddish-white  deposit,  pure  blood  is  sometimes 
voided  with  the  last  drops  of  urine.  The  patient  becomes 
anaemic  and  thin,  and  the  general  health  rapidly  fails  if 
the  disease  is  long  continued.  Severe  cystitis,  pyelitis, 
and  disseminated  suppuration  of  the  kidneys,  sooner  or 
later  supervene,  and  if  the  intestines  are  also  affected 
dysenteric  discharges  add  to  the  exhaustion.  The  ova 
not  infrequently,  when  imbedded  in  a  plug  of  mucus, 
form  the  nucleus  of  a  stone  in  the  bladder,  and  the  fre- 
quency of  stone  among  the  natives  of  Egypt  is  no  doubt 
attributable  to  this  circumstance. 

131.  Morbid  Anatomy. — The  Bilharzia  chiefly  af- 
fects the  bladder,  and  in  many  cases  the  disease  is  fortu- 


368  DISEASES    OF    THE    KIDNEY. 

nately  limited  to  it,  when  it  extends  to  the  kidneys  the 
condition  of  the  patient  becomes  very  serious.  On  examin- 
ing a  bladder  that  has  been  the  seat  of  the  disease,  we 
find  it  hypertrophied  with  thick  hard  walls,  patches  of 
ecchymosed  swollen  mucous  membrane,  studded  with 
small  branched  mucoid  vegetations,  and  incrusted  often 
with  phosphatic  deposits.  Under  the  microscope,  sections 
show  the  ova  of  the  Bilharzia  in  the  deeper  layers  of  the 
mucous  membrane,  and  also,  but  in  smaller  numbers,  in 
the  submucous  tissue,  and  in  the  fibrous  tracts  between 
the  muscular  bundles.  When  the  ureters  and  the  pelvis 
of  the  kidney  are  attacked,  their  diameter  becomes  nar- 
rowed at  the  point  alfected,  and  may  thus  give  rise  to 
hydro-nephrosis  or  pyo-nephrosis,  whilst  the  kidneys  are 
hypersemic  and  may  become  the  seat  of  disseminated  sup- 
puration. 

132.  Treatment. — When  the  disease  is  limited  to  the 
bladder,  good  results  have  been  obtained  by  Dr.  Harley 
by  injecting  the  bladder  by  means  of  a  solution  of  potas- 
sium iodide,  commencing  with  three  up  to  five  grains  to 
the  fluid  ounce  ;  this  injection  is  to  be  retained  for  three 
hours.  Beyond  the  nasal  and  catarrhal  symptoms,  and 
the  iodine  taste,  the  drug  never  produces  the  shghtest 
urethral  or  vesical  irritation.  The  first  effect  is  to  bring 
away  branched  mucous  casts  of  the  tunnels  formed  by  the 
parasite,  with  hosts  of  imbedded  eggs.  Attached  to  these 
casts  certain  so-called  "colloid  corpuscles"  are  often  ob- 
served, sometimes  singly,  sometimes  in  groups.  The 
largest  of  these  resemble  minute  grains  of  tapioca,  pos- 
sessing a  jelly-like  transparency  and  faint  amber  tinge. 
Dr.  Harley  thinks  these  corpuscles  are  derived  from  the 
prostate.  These  casts  after  a  time  lose  thek  cylindrical 
character  and  are  replaced  by  long  skin-Hke  membranes 
almost  destitute  of  ova,  whilst  at  the  same  time  the  ova  dis- 


BILHAKZIA    HjEMATOBIA.  369 

appeared  from  the  urine.     When  Dr.  Harley's  patient  left 
England  he  still  passed  a  few  ova,  not  however  in  masses 
of  mucus  but  in  soft  blood  clots.    When,  however,  the  dis- 
ease extends  to  the  ureters  and  pelvis  of  the  kidneys,  this 
local  treatment,  though  it  should  be  directed  against  the 
parasite  in  the  bladder,  is  of  no  avail,  and  internal  reme- 
dies must  be  employed,  of  these  quassia,  extract  of  male 
fern,  and  turpentine,  have  been  tried,  and  under  their  ad- 
ministration, quantities  of  ova  have  been  brought  away. 
To  these  I  would  suggest  the  continued  use  of  biborate  of 
soda,  solutions  of  which  have  a  poisonous  influence  on  the 
ova  of  most  parasites,  whilst  as  a  medicine  it  can  be  given 
without  any  disturbance  to  the  patient's  general  health, 
and  is   one   of  the   few  remedies   that   pass   unchanged 
through  the  system  into  the  urine.     It  has  also  another 
advantage,  in  relieving  the  cystitis  and  pyelitis  if  present, 
and  by  dissolving  deposits  of  uric  acid  on  the  ova,  dimin- 
ishes the  chance  of  the  secondary  formation  of  calculous 
deposits.     The  following  draught  administered  three  times 
will  be  found  very  useful  as  an  adjunct  to  the  topical 
treatment.      Biborate  of  soda,  gr.  xv.,  Chian  turpentine, 
gr.  X.,  acacia  mixture,  3  ii.,  and  chloroform  water,  ^  i.,  to 
which   opium  in  some  form  may  be  added,  if  there  be 
much  pain  or  irritability  of  the  urinary  passages. 

The  prophylactic  recommendations  consist  in  ordering 
all  water  used  for  drinking  in  the  countries  liable  to  the 
disease,  to  be  boiled  and  filtered,  and  raw  salads  and  mol- 
luscous animals  to  be  avoided.  Dr.  Harley  also  rightly 
insists  on  the  drinking  water  being  conveyed  in  covered 
channels  and  kept  distinct  of  all  sewage  communication, 
so  that  the  urinary  and  faecal  products  of  those  infected 
with  the  disease  may  not  be  accidentally  mixed  with  it. 


BB 


370  DISEASES    OF    THE    KIDNEY. 


FiLAEiA  Sanguinis  Hominis. 

133.  Etiology.' — The  small  worms  which  are  so  often 
found  in  the  blood  of  patients  suffering  from  tropical  dis- 
eases, were  first  discovered  by  Lewis  in  1872,  and  named 
by  him  filaria  sanguinis  hominis,  are  the  embryo  of  a 
nematode  worm  discovered  four  years  later  by  Bancroft, 
and  which  has  been  named  after  him  filaria  Bancrofti. 
As  these  parasites  are  supposed  to  have  a  special  relation 
in  the  causation  of  tropical  haemato-chyluria,  and  as  they 
appear  in  the  urine  in  these  cases,  they  are  entitled  to  a 
full  description  under  the  head  of  renal  parasites,  and 
both  they  and  chyluria  may  well  be  described  together. 
The  parent  worms  according  to  Dr.  Manson  [Path. 
Soc.  Trans.,  1881)  inhabit  the  lymphatics  of  the  body, 
the  two  sexes  probably  living  together.  Only  a 
small  part  of  the  male  worm  has  hitherto  been  found, 
it  is  considerably  smaller  than  the  female,  The  latter 
is  a  long,  slender,  hair-like  animal,  quite  three  inches  in 
length,  but  only  ^ho  i^  breadth,  of  an  opaline  appearance, 
looking  as  it  lies  in  the  tissues  "like  a  piece  of  catgut 
animated  and  wriggling."  A  narrow  alimentary  canal 
runs  from  the  simple  club-like  head  to  within  a  short  dis- 
tance of  the  tail,  the  remainder  of  the  body  being  enth-ely 
occupied  with  the  reproductive  organs.  As  fully  formed 
embryos  can  be  seen  under  the  microscope  escaping  from 
the  vagina,  it  is  supposed  that  under  ordinary  circumstances 
the  animal  is  viviparous.  The  parent  filaria  thus  lying  in 
a  lymphatic  channel  emits  her  embryos  into  the  lymph 
stream.  The  embryo  is  a  long,  slender,  snake-like  animal, 
averaging  from  J^  to  gL  of  an  inch  in  length,  and  ^-^  of 
an  inch  in  breadth,  perfectly  transparent  and  apparently 
sti'uctureless   (fig.    36).      The  anterior  part   of  the  body 


FILAEIA    SANGUINIS    HOMINIS. 


371 


tapers  slightly,  and  at  its  extremity  a  pouting  movement 
as  if  of  breathing  is  to  be  noticed  ;  posteriorly  the  body 
tapers  .down  to  a  fine  point.  It  is  covered  by  a  delicate 
sheatli  about  one-third  longer  than  the  body,  so  that  it  is 
never  fully  occupied  by  the  animal,  and  forms  a  lash- 
like projection  (^fig.   36,   c)   at  the   head  or  tail  or  both, 


Fig.  36. — a.  Filaria  Sanguinis  Hominis.     x  250.     (After  Lewis). 
h.  Ovum.     X  250.     (After  Cobbold). 

according  to  the  movements  of  the  animal — the  lash 
always  trailing  behind.  One  of  the  most  remarkable 
phenomena  connected  with  the  disease,  is  that  the  em- 
bryos disappear  from  the  blood  stream  and  reappear  at 
certain  periods  of  the  day.  Thus  they  are  absent  during 
the  day  and  are  present  at  night,  the  greatest  number 
being  observed  at  midnight,  whilst  by  3  a.m.  a  sensible 
decline  is  observed,  and  by  9  a.m.  they  have  quite  disap- 
peared except  an  occasionally  belated  straggler.  At 
6  p.m.  they  again  begin  to  appear  and  increase  as 
before  up  to  midnight.  Dr.  S.  Mackenzie  [Path.  Soc. 
Trans.,  1882)  by  turning  night  into  day,  induced  the 
filaria,  in  the  case  under  observation,  to  change  their  noc- 
turnal into  diurnal  habits,  thus  making  it  clear  that  the 
periodicity  of  filarial  migration  is  dependent  on  the  mov- 
ing and  resting  conditions  of  the  patient,  and  indepen- 
.dent  of  the  time  when  the  chyle  reaches  the  circulation. 

bb2 


372  DISEASES    OF    THE    KIDNEY. 

Dr.  Manson  (Path.  Soc.  Trans.,  1881)  has  described  how 
these  embryos  developed  in  the  blood,  require  the  aid 
of  an  "intermediary  host"  to  enable  them  to  attain 
maturity.  The  host,  he  has  shown,  is  the  female  of  a 
certain  species  of  mosquito.  This  animal  piercing  the 
skin  of  a  filaria-infected  subject,  becomes  infested  with 
embryos ;  some  are  ejected,  some  perish,  but  a  few 
undergo  an  extraordinary  metamorphosis  in  the  body 
of  their  host.  By  the  time  this  metamorphosis  is 
completed  (four  to  six  days),  the  mosquito  who  has  de- 
posited her  ova  and  whose  stomach  is  emp'ty,  except  for 
these  metamorphosed  embryos,  dies,  probably  falling  into 
the  water  in  which  her  eggs  were  laid ;  from  thence 
the  embryos  find  their  way  into  the  human  stomach, " 
whether  directly  by  the  drinking  water,  or  through  the 
channel  of  another  host  is  a  disputed  point,  but  once  in 
the  stomach  it  bores  its  way  to  the  lymphatics,  and  work- 
ing up  stream  pierces  the  glands  and  finally  arrives  at  its 
permanent  abode  in  some  distant  lymphatic  vessel.  Here 
it  is  followed  by  one  of  the  opposite  sex  and  they  may  live 
and  grow  together  comfortably  for  years,  breeding  a 
numerous  progeny,  and  without  necessarily  giving  annoy- 
ance to  their  human  host.  But  unfortunately  the  female 
worm  is  liable  to  occasional  miscarriages  with  her  numer- 
ous offspring,  that  is  to  say  the  immature  embryo  instead 
of  being  born  in  its  free  and  elongated  state,  escapes  in  an 
unstretched  condition  enclosed  as  an  ovum  (fig.  36,  6) ;  and 
as  in  this  state  in  its  smallest  diameter  it  is  five  times 
greater  than  that  of  the  fully  outstretched  embryo,  we 
can  readily  understand  that  when  carried  into  the  lymph 
stream  it  should  plug  the  smaller  vessels,  when  they  break 
up  into  smaller  channels.  There  will  thus  be  complete 
stasis  of  lymph  along  the  line  of  this  particular  vessel,  as 
far  back  as  the  first  anastomosing  lymphatic.     As  more 


CHYLURIA.  878 

immature  embryos  pass,  this  process  of  obstruction  ot  the 
lymphatic  vessels  and  stasis  of  lymph  will  go  on  increas- 
ing till  eventually  a  rupture  of  a  lymphatic  vessel  occurs. 
Should  the  parent  worm  inhabit  a  lymphatic  trunk  in  the 
pelvic  or  lumbar  region,  the  stasis  caused  by  the  imma- 
ture embryos  may  involve  the  lymphatics  of  the  kidney, 
ureter,  or  bladder,  and  chyluria  result. 


Chyluria. 

184.  Symptoms. — In  this  disorder  the  urine  assumes 
a  milky  appearance,  and  is  usually  slightly  tinged  with 
blood,  and  yields  on  standing  a  delicate  fibrinous  clot, 
which  possesses  the  power  of  decomposing  peroxide  of 
hydrogen.  Beyond  the  addition  of  the  finely  divided  fatty 
matter,  the  blood,  and  the  fibrinous  clot,  the  urine  is  but 
little  altered  in  its  general  characters.  After  separating 
these  abnormal  elements,  I  have  found  the  amount  of  urea 
excreted  in  the  twenty-four  hours  to  be  generally  normal, 
though  the  amount  of  water  excreted  daily  is  usually  in- 
creased. An  analysis  of  the  fatty  material  shows  it  to  be 
composed  of  saponifiable  fatty  matters,  cholesterin  and 
lecithin.  The  albumins  consist  of  serum  albumin  and 
fibrin,  the  latter  may  amount  to  as  much  as  -18  per  cent. ; 
peptones  are  invariably  to  be  found,  as  also  traces  of  indi- 
can.  The  amounts  of  these  abnormal  constituents  vary 
considerably ;  in  a  very  milky-looking  urine  yielding  a 
considerable  amount  of  clot,  the  total  fatty  matter 
amounted  to  0*75,  and  the  albumins  to  -80  per  cent.  On 
the  other  hand,  in  a  lymphous  looking  urine,  yielding  a 
yellow  gelatinous  clot,  the  fat  only  amounted  to  0-06  per 
cent.,  whilst  the  albumins  were  not  so  greatly  diminished, 
being  0*61  per  cent. 


374  DISEASES    OF    THE    KIDNEY. 

The  discharge  of  chyle  or  lymph  by  the  urine  is  not 
always  uniform.  In  some  cases  it  is  intermittent,  days 
or  eveii  months  elapsing  between  the  discharge.  In  some 
rare  cases  it  never  returns  after  its  first  appearance. 
Even  when  the  discharge  is  permanent  considerable  vari- 
ations occur  in  the  amount  discharged  from  day  to  day. 
Intermittent  chyluria  is  generally  observed  ia  the  tropical 
cases,  which  are  generally  supposed  to  be  caused  by  the 
rupture  of  the  renal  lymphatics  by  the  pressure  of  the  im- 
mature filarial  embryos,  and  the  intermittency  is  the  result 
of  the  same  cause.  For  a  communication  having  been  made 
with  the  renal  passages  through  the  lymphatics,  by  means 
of  these  immature  embryos,  the  passage  may  also  become 
occluded  whenever  the  parent  happens  to  abort,  and  the 
discharge  of  chyle  will  be  arrested  till  the  obstruction  is 
overcome.  On  the  other  hand,  the  j)ermanent  discharge 
of  chyle  is  most  generally  noticed  in  the  European  cases, 
in  which  the  communication  of  the  lymphatics  with  the 
urinary  passages  is  brought  about  by  traumatic  agency, 
though  in  these  cases  an  occasional  intermittency  may 
occiu",  if  the  passage  happens  to  be  temporarily  obstructed 
by  a  fibrinous  clot.  The  diurnal  variations  in  amount 
passed  in  these  cases,  however,  depend  on  the  pressure 
of  the  lymph  in  the  lymphatic  vessels,  and  the  amount  of 
chyle  is  decidedly  increased  after  meals  and  after  exercise. 
The  amount  of  blood  varies  considerably,  it  is  rarely  en- 
tirely absent  giving  a  pink  tinge  to  the  bottom  of  the 
vessel,  and  to  the  clot  on  standing  ;  it  is,  however,  much 
more  abundant,  in  the  intermittent  cases,  no  doubt  from 
the  rupture  of  smaU  vessels  from  the  increased  pressure 
in  the  lymphatics.  Chyluria  may  exist  without  giving 
rise  to  any  other  symptoms  except  the  milky  appearance 
of  the  urine,  and  the  general  health  of  the  patient  may 
not  be  affected  by  it.     In  many  cases,  however,  dragging 


CHYLUKIA.  .  375 

pains  across  the  loins  are  complained  of,  especially  in  in- 
termitting cases  just  before  the  discharge  occnrs.  If  the 
coagulation  of  the  fibrin  occurs  within  the  pelvis  of  the 
kidney,  there  may  be  renal  colic  ;  if  in  the  bladder,  stran- 
gury with  obstruction  to  the  passage  of  urine. 

The  exact  point  at  which  the  chyle  reaches  the  urinary 
tract  has  yet  to  be  determined,  it  may  as  Dr.  Stephen 
Mackenzie  has  suggested  {Path.  Soc.  Trans.,  1882)  take 
place  either  (1")  between  the  vascular  and  lymphatic  sys- 
tems at  their  entrance  into  the  kidney,  or  (2)  between 
the  renal  lymphatics  and  uriniferous  tubes  of  the  kidney, 
or  (3)  as  Dr.  Eoberts  has  suggested  in  some  cases  by  the 
bladder.  In  Dr.  Mackenzie's  case,  the  thoracic  duct  was 
found  to  be  impervious,  one  and  a  half  inch  above  the 
aortic  opening  of  the  diaphragm,  whilst  the  iliac,  lumbar 
and  renal  lymphatics  were  very  much  enlarged,  especially 
the  left,  whilst  the  left  renal  lymphatics  contained 
numerous  hard  round  masses,  apparently  calculous.  As 
already  stated,  the  malady  does  not  necessarily  affect  the 
general  health,  and  the  patient  may  live  for  many  years. 
Eoberts  cites  a  case  in  which  the  disease  commenced  at 
twenty-five,  and  continued  to  seventy-eight  years  of  age, 
when  the  patient  was  still  aHve,  and  I  occasionally 
see  a  patient  who  has  had  the  disease  in  an  intermit- 
tent form  for  fifteen  years,  and  whose  general  health  is 
excellent,  and  who  the  last  few  years  has  gained  rather 
than  lost  weight.  Still  the  continued  drain  of  nutritive 
material  must  tell,  and  though  so  long  as  they  are  not  ex- 
posed to  vicissitudes  or  severe  illness,  and  they  are  able  to 
balance  the  loss,  they  may  live,  yet  they  are  liable  to  suc- 
cumb to  intercurrent  disease,  especially  pulmonary  affec- 
tions. For  this  reason  it  is  necessary  to  attend  carefully  to 
their  diet  and  shield  them  from  cold  winds,  damp  soils, 
and  malarious  influences.     The  diet  should  be  abundantly 


376  DISEASES    OF    THE    KIDNEY. 

fatty,  milk,  cream,  butter,  bacon,  and  during  inclement 
weather,  cod-liver  oil.  The  under  clothing  should  be  of 
flannel  in  all  seasons,  with  chamois  leather  vests  for 
winter  use.  Care  should  be  exercised  in  selecting  their 
residence,  if  in  England  the  sub- soil  should  be  carefully 
drained  if  not  naturally  dry,  and  the  house  sheltered 
from  the  east  winds,  whilst  those  who  can  afford  it,  should 
winter  in  the  South  of  France  or  Italy.  With  a  view  to 
diminishing  the  discharge  through  the  lymphatics,  abdo- 
minal pressure  has  been  resorted  to,  and  a  horse-shoe  tour- . 
niquet  apphed  to  the  abdomen,  which  has  certainly  had  the 
effect  of  temporarily  arresting  the  discharge  of  chyle  into 
the  urine.  But  the  principle  is  wrong,  for  we  ought  to 
encourage  rather  than  obstruct  the  flow  if  it  has  been 
established,  for  by  damming  it  up  we  only  increase  the 
pressure  in  the  lymphatic  vessels,  and  lead  to  their  further 
dilatation,  whilst  powerful  compression  of  the  abdomen 
must  have  an  injurious  influence  if  long- continued,  on  the 
general  health  of  the  patient.  If  attempted  at  all,  it 
should  be  in  cases  that  evidently  are  of  traumatic  origin, 
in  which  we  may  hope  that  an  arrest  of  the  passage  of 
lymph  through  the  lesion  in  the  walls,  may  permit  its 
occlusion,  though  the  impossibiUty  of  determining  the  exact 
point  where  the  communication  takes  place,  renders  such  a 
probability  a  matter  of  extreme  chance.  When  the  dis- 
ease, however,  is  undoubtedly  due  to  filarial  abortion,  only 
harm  can  result  from  its  employment.  Our  chief  efforts 
must  be  directed  in  these  cases  to  secure  the  death  and 
removal  of  the  parent  worm.  For  this  purpose,  many 
remedies  have  been  suggested,  gallic  acid,  mangrove  bark, 
benzoate  of  soda,  and  direct  anthelmintics,  are  the  ones 
most  employed.  Dr.  Simpson  of  Assam  (Lancet,  Nov. 
2ith,  1883)  records  four  cases  of  chyluria ;  in  two  of 
which  the  urine  became  natural  after  five  grains  of  gallic 


CHYLURIA. 


377 


acid,  followed  by  rrixv-doses  of  perchloride  of  iron,  three 
times  a  day,  had  been  administered  for  ten  days.  In  two 
others  perchloride  of  iron  was  given,  with  twenty-grain- 
doses  of  quinine  every  morning,  when  the  urine  became 
natural  in  fourteen  days  ;  of  these  cases,  only  one  recurred 
a  second  time.  Dr.  Acton  of  Winnipeg  {Lancet,  Oct.  20th, 
1883)  reports  favourably  of  salicylate  of  iron  in  large  doses. 
A  patient  of  mine  who  has  been  under  treatment  in  vari- 
ous parts  of  the  world  (for  the  disease  at  different  times) , 
has  experienced  most  rehef  from  terebinthine  remedies. 
It  is  probable  that  these  remedies,  even  if  they  do  not 
cause  the  expulsion  of  the  worm,  may  prevent  the  tend- 
ency fco  the  premature  expulsion  of  the  embryos,  and  thus 
keep  the  disease  in  abeyance.  In  Dr.  Mackenzie's  case, 
the  accession  of  febrile  symptoms  put  a  stop  at  once  to 
the  appearance  of  filarise  in  the  blood,  by,  he  supposes, 
causing  the  death  of  the  parent  worm,  but  this  event  most 
likely  sealed  the  death  warrant  of  the  patient,  for  the  post- 
mortem examination  showed  that  the  double  pleurisy  of 
which  the  patient  was  the  victim,  was  due  to  inflamma- 
tion originating  in  the  thoracic  duct,  probably  excited  in 
the  first  instance  by  the  disturbed  parent  worms.  On  the 
other  hand,  many  cases  recover  spontaneously,  the  parent 
worms  being  discharged,  apparently  without  any  unpleasant 
symptoms  being  occasioned  during  the  process  of  removal. 
In  others,  the  discharge  of  chyle  by  the  urinary  passages 
ceases,  whilst  filarias  are  still  found  in  the  blood.  In  these 
cases  which  unfortunately  are  of  very  rare  occurrence,  the 
lesion  in  the  lymphatic  vessels  probably  becomes  closed, 
whilst  the  parent  worm  ceases  to  abort.  The  prophy- 
lactic treatment  is  the  same  as  recommended  for  the 
prevention  of  endemic  haamaturia,  viz.,  avoidance  of  sus- 
pected drinking  water.  As  the  female  mosquito  lays 
her  eggs  in  stagnant  pools,  the  water  from  these  should 


378  DISEASES    OF    THE    KIDNEY. 

be  scrupulously  avoided,  both  for  drinking  purposes, 
and  for  wasliing  fruit  and  uncooked  vegetables,  salads, 
etc.  "When  circumstances  absolutely  compel  its  use,  it 
should  be  subjected  to  prolonged  boiling,  and  careful  fil- 
tration. 


Eare  Eenal   Parasites. 

136.  Strongylus  Gigas  is  a  large  nematoid  worm^ 
which  is  occasionally  found  in  the  renal  pelvis  of  dogs, 
wolves,  weasels,  and  other  carnivorous  beasts  of  prey, 
rarely  in  the  ox  and  horse,  and  still  "more  rarely  in  man. 
It  resembles  in  appearance  a  large  ascaris  lumbricoides, 
but  is  distinguished  from  it  by  its  huge  size,  and  by  having 
six  oral  papillse  instead  of  three.  The  female  is  larger  than 
the  male,  the  former  may  attain  the  length  of  thirty  inches, 
whilst  the  latter  rarely  exceeds  twelve  to  fourteen  inches. 
So  rare  is  this  parasite  among  human  beings,  that  only 
seven  authentic  cases  are  recorded.  Nothing  is  known 
with  regard  to  the  life-history  of  the  parasite,  or  how  it.  is 
introduced  into  the  body.  The  symptoms  it  gives  rise  to, 
are  the  same  as  those  caused  by  any  foreign  body  in  the 
renal  passages,  viz.,  colic,  hsematuria,  and  pyuria.  Long 
clots  of  blood  from  the  urethra,  or  lumbrici  which  have 
been  discharged  into  the  chamber  vessel  containing  urine, 
have  sometimes  been  hastily  taken  for  a  "  gigas,"  but  a 
very  slight  examination  is  sufficient  to  correct  the  error. 
So  rarely  are  these  animals  observed  in  man,  that  no  case 
has  now  been  recorded  for  some  years,  and  the  only  speci- 
men I  am  acquainted  with  is  that  in  the  Eoyal  College  of 
Surgeons.  Pentastoma  Denticulatum,  a  minute  parasite 
which  occasionally  is  found  under  the  capsule  of  the  liver 
of  herbivorous  animals,  and  sometimes  (in  Germany)  in 
man.     It  has  only  once  been  found  under  the  capsule  of 


BARE    RENAL    PARASITES.  379 

the  kidney  of  a  patient  who  died  from  Bright's  disease. 
In  its  larval  state  it  is  boat- shaped,  having  at  its  fore  part 
four  hooklets  or  anchors,  at  its  side  spines  said  to  re- 
semble oars.  In  this  state  it  is  found  in  the  viscera.  In 
the  adult  form  it  developes  into  a  small  maggot  found  in 
the  nasal  cavities  of  dogs  and  wolves,  introduced  whilst 
the  animals  were  devouring  the  offal  of  cattle  infested 
with  the  larvEe. 

136.  Extra-renal  ^jarcmies.  —  When  a  communication 
exists  between  the  intestines  and  the  urinary  passages, 
lumbrici  ascarides,  or  the  joints  of  tape-worms  may  be 
voided  per  urethram,  or  they .  may  simply  escape  from 
the  bowel  into  the  chamber  vessel.  So  also,  the  para- 
sites of  other  animals  may  accidentally  or  intention- 
ally find  their  way  to  the  urine,  an  interesting  account 
of  such  deception  is  given  in  Beale's  Archives  of  Medicine, 
'vol.  i.,  p.  290.  Dr.  Curgenven  (Brit.  Med.  Jour.,  June 
14th,  1884)  relates  an  interesting  case  in  which  the 
mucous  membrane  of  the  whole  urinary  tract  was  invaded 
with  a  fungus  growth,  the  spores  probably  coming  in  con- 
tact in  the  first  instance  with  the  orifice  of  the  urethra  and 
parts  adjacent,  and  giving  rise  to  the  growth  of  mycelium, 
which  spread  up  the  urethra  to  the  bladder  and  ureters. 


380  DISEASES    OF    THE    KIDNEY. 


CHAPTEE  YIII. 

Abnormalities    of    the     Kidneys,    including     Moveable 
Kidney. 

Under  this  liead  we  shall  consider  1.  Abnormalities  of 
Position,  and  2.  Abnormalities  of  Form  and  Number,  the 
former  being  clinically  much  the  more  important. 


I.  ABNORMALITIES  OF  POSITION. 

137.  The  normal  position  of  the  kidneys  has  already 
been  laid  down  in  Chap.  I.,  p.  7,  and  while  the  positions 
there  assigned  to  them,  are  to  be  regarded  as  merely  the 
average  of  a  number  of  instances,  still  the  variations  are 
for  practical  purposes  not  great.  Assuming  then,  that 
the  kidneys  are  situated  in  the  upper  and  back  part  of 
the  abdominal  cavity,  the  hilum  of  each  on  a  level  with 
the  first  lumbar  spine,  two  and  a  half  inches  from  the 
middle  hne,  we  may  say  that  if  the  hilum  is  displaced 
from  this  point  by  an  inch  and  a  half,  the  case  comes 
already  within  the  abnormal  or  the  morbid. 

Such  displacements  from  the  normal  position,  fall  under 
two  categories.  1.  Fixed  Malpositions  of  the  Kidney,  and 
2.  Moveable  Kidney,  and  under  each  of  these  heads  we 
shall  have  to  consider  the  congenital  and  the  acquired 
varieties. 


MALPOSITIONS.  381 


1.    Fixed  Malpositions  of  the  Kidney. 

138.  In  these  cases  the  kidney  is  fixed  in  an  abnormal 
position,  which  maybe  congenital,  or  acquired  subsequently. 

The  displacement  in  congenital  case.s  is  most  frequently 
downwards,  and  in  the  majority  of  instances  affects  the 
left  kidney.  Of  twenty- one  cases  collected  by  Dr.  William 
Eoberts,  in  every  instance  only  one  kidney  was  involved, 
in  fifteen  cases  the  left,  in  six  the  right.  Weisbach  {Wien. 
Med.  Wochenschrift,  1867)  makes  the  disproportion  much 
more  marked,  viz.,  thirty-five  to  eight.  He  also  states 
that  of  twenty-nine  cases,  twenty  were  men,  only  nine 
women.  In  other  words,  while  mobility  of  the  .kidney  as 
we  shall  see,  occurs  more  frequently  on  the  right  side,  and 
in  the  female  sex,  fixed  malpositions  occur  more  frequently 
on  the  left  side,  and  in  the  male  sex.  The  displaced 
organ  lies  usually  in  the  region  of  the  sacro-iliae  joint  on 
the  brim  of  the  true  pelvis,  and  frequently  as  in  a  case 
recorded  and  sketched  by  Dr.  MacWilliam  {JJrit.  Med. 
Jour.,  7th  Oct.,  1882)  in  front  of  the  great  vessels.  Its 
shape  is  rarely  reniform,  more  generally  oval  and  flattened 
with  persistent  foetal  lobulation.  The  ureter  leaves  it  on 
its  anterior  aspect,  its  vascular  supply  is  derived  usually 
from  the  neighbouring  vessels,  and  it  is  interesting  to  note 
that  the  corresponding  supra-renal  capsule  is  not  dis- 
placed with  it. 

Such  a  congenitally  displaced  kidney  has  been  mistaken 
for  a  tumour,  and  energetically  treated  in  accordance  with 
the  diagnosis.  It  has  also  presented  before  the  descend- 
ing foetal  head,  causing  considerable  difficulty  in  delivery. 
As  a  rule,  however,  the  condition,  giving  rise  to  no  symp- 
toms, is  not  recognised  during  life.  If  the  possibility  of 
such  a  condition  is  present  to  the  mind  of  the  examinmg 


382  DISEASES    OF    THE    KIDNEY. 

pliysician  (and  this  proviso  is  the  most  important  element 
in  the  diagnosis  of  all  abnormal  conditions  of  the  kidney), 
then  a  mistake  will  be  avoided  if  attention  is  paid  to  the 
smooth,  rounded,  elastic  character  of  the  mass,  to  the 
feeling  of  faintness  and  nausea  caused  by  pressure  upon  it, 
and  to  the  flattening  and  tympanitic  resonance  occasionally 
present  in  the  usual  position  of  the  kidney.  In  case  of 
doubt,  a  rectal  examination  should  not  be  neglected. 

Of  the  acquired  malx^ositions  of  the  kidney,  the  most  im- 
portant is  that  due  to  inflammation  in  the  tissue  surround- 
ing a  moveable  kidney  with  subsequent  fixation.  This 
condition  we  shall  discuss  under  the  head  of  moveable 
kidney.  The  displacement  due  to  enlargement  or  mahg- 
nant  growth  in  neighbouring  organs,  will  be  simply  an 
incident  in  the  more  serious  disease,  important  only  if 
such  displacement  causes  pressure  on  the  ureter  or  on  the 
renal  vessels. 


2.    Moveable  Kidney. 

139.  The  kidney  is  normally  a  retro-peritoneal  organ, 
lying  in  the  position  already  defined,  largely  within 
the  bony  thorax.  It  is  provided  with  two  capsules, 
the  fibrous  —  thin  but  strong,  and  closely  adherent 
to  the  organ,  the  fatty — of  veiy  variable  thickness  in 
different  individuals,  and  in  the  same  individual  at 
different  times.  The  fatty  capsule  is  connected  by  loose 
areolar  tissue,  both  with  the  fibrous  capsule  on  the  one 
hand,  and  with  the  iieritoneum  and  abdominal  wall  on  the 
other.  It  forms,  therefore,  as  will  readily  be  understood, 
a  most  important  element  in  the  etiology  and  pathology 
of  moveable  kidney.  Landau  in  his  admirable  chnical 
monograph    {Die    Wanderniere   der   Frauen,     1881,    p.    9) 


MOVEABLE    KIDNEY.  383 

describes  the  sub-peritoneal  areolar  tissue  of  the  child  as 
dividing  into  two  layers,  one  of  which  remains  immediately 
sub-peritoneal,  while  the  other  passing  behind  the  kidney 
and  its  vessels,  forms  a  sort  of  suspensory  ligament  for  the 
kidney  (Englisch)  connecting  it  closely  with  the  perito- 
neum, and  loosely  also  with  the  abdominal  wall.  Only 
after  the  tenth  year  does  the  areolar  coat  thus  formed 
develop  in  its  meshes  the  fat  which  constitutes  the  fatty 
capsule  of  the  kidney. 

The  kidneys  are  in  close  relation  anteriorly,  with  the 
hepatic  and  splenic  flexures  of  the  colon,  and  it  is  to  be 
noted  as  Landau  points  out,  that  the  splenic  flexure  of  the 
colon  is  much  more  firmly  fixed  in  its  position  than  is  the 
hepatic.  The  difference  is  due  principally  to  the  strong 
membranous  band,  termed  the  pleuro-colic  fold  which  con- 
nects the  splenic  flexure  with  the  inner  wall  of  the  thorax, 
and  supports  the  spleen  on  its  upper  surface.  We  shall 
revert  to  this  point  again  in  discussing  the  greater  fre- 
quency of  right  moveable  kidney  than  of  left.  But  by  far 
the  most  important  of  the  structures  retaining  the  kidneys 
in  position,  are  the  renal  vessels,  and  more  especially  the 
renal  arteries.  These  being  connected  with  the  practically 
immovable  aorta  and  vena  cava,  act  as  a  tether  to  the 
kidney,  allowing  even  in  case  of  mobility,  only  a  limited 
range  downward,  forward,  and  inward,  upward  displace- 
ment being  rendered  practically  impossible  by  the  presence 
of  the  liver  and  spleen. 

Such  displacement  of  the  kidney  behind  the  peritoneum, 
constituting  moveable  kidney,  does  in  fact  occur,  and  that 
too  not  unfrequently.  EoUet  states  {Pathologie  tmd 
Therajyie  der  beweglichen  Niere,  1866,  p.  13)  from  the  ex- 
amination of  five  thousand  five  hundred  patients,  that 
moveable  kidney  occurs  once  in  two  hundred  and  fifty 
cases,  adding,  however,  that  this  proportion  is  but  a  rough 


384  DISEASES    OF    THE    KIDNEY. 

approximation.  As  bearing  on  this  point,  it  maybe  stated 
on  the  one  hand  that  in  only  a  very  small  proportion  of 
the  cases  in  which  it  occurs,  do  symptoms  present  them- 
selves, drawing  attention  to  the  condition,  while  on  the 
other  hand  in  the  majority  of  instances  where  such  symp- 
toms do  occur,  the  cause  will  be  overlooked,  not  being 
present  to  the  mind  of  the  physician. 

As  a  very  rare  condition  the  kidney  may  be  more  or 
less  completely  surrounded  by  peritoneum,  being  then 
connected  with  the  spine  by  a  double  fold  of  membrane 
termed  a  meso-nephron.  This  abnormality  is  invariably 
congenital,  and  will  usually  be  found  associated  with 
other  abnormalities  of  the  peritoneum.  The  kidney  in 
such  cases  is  moveable,  and  we  have  no  means  of  diagnos- 
ing the  condition  from  that  above  described.  Sir  William 
Jenner  proposed  to  reserve  the  term  floating  kidney,  for 
this  form  of  moveable  kidney,  in  which  case  floating  and 
moveable  kidney  would  be  synonymous  with  congenital 
and  acquired  mobihty  of  the  kidney.  The  former  condi- 
tions will  undoubtedly  even  more  rarely  than  the  latter 
give  rise  to  symptoms,  and  what  we  are  about  to  say  wiU 
have  almost  exclusive  reference  to  moveable  kidney  of  the 
acquired  variety. 

140.  Causes. — In  any  enquiry  as  to  the  causes  of 
moveable  kidney,  certain  statistical  facts  must  be  borne  in 
mind.  In  the  first  place  it  occurs  with  very  much  greater 
frequency  among  women,  than  among  men.  Of  290  cases 
collected  by  Newman  [Malpositions  of  the  Kidney,  1883,  p. 
13)  252  were  women,  and  38  were  men,  i.e.,  about  one 
male  case  for  seven  female.  Again  as  to  age,  by  far.  the 
greater  portion  of  cases  occur  between  the  ages  of  25  and 
40  years,  that  is  as  Dr.  William  Eoberts  states,  roughly 
within  the  childbearing  period  in  women.  Lastly,  the 
condition  occurs  much  more  frequently  on  the  right  than 


MOVEABLE    KIDNEY.  385 

on  the  left  side.     Among  178  cases  cited  by  Landau  {loc. 
cit.,  p.  14)  the  right  kidney  was  moveable  in  151,  the  left 
in  13  and  both  kidneys  in  14.    It  is  impossible  to  avoid  the 
conclusions  suggested  by  these  statistics,  that  women  are 
specially  liable  to  moveable  kidney,  and  that  more  parti- 
cularly during  the  period  of  childbearing.     In  support  of 
this  we  find  from  a  table  compiled  by  Landau  {loc.  cit.,  p. 
103)  that  a  very  considerable  proportion  of  the  cases  have 
born  a  large  number  of  children  in  rapid  succession.     The 
result  of  reiuated  pregnancies  is  in  the  first  place  to  produce 
great  relaxation  of  the  abdominal  walls  and  of  the  pelvic 
floor,  and  in  the  second  place  by  the  alternating  upward 
pressure,  and  sudden  subsidence  of  the  kidneys  to  cause  a 
greater  mobility  of  these  organs.     This  relaxation  with  the 
consequent   pendulous   abdomen,    and   diminished  intra- 
abdominal pressure,  occurs  most  markedly  in  women  of  the 
lower  classes,  who  are  frequently  engaged  in  hard  manual 
labour  within  a  few  days  after  delivery.     Accordingly  we 
find  prolapsed  uterus  and  moveable  kidney,  very  frequently 
co-existent,  so  commonly  indeed  that  the  first  has  been 
alleged  as  a  cause  of  the  second,  the  intermediate  link 
being  hydro-nephrosis  due  to  urinary  obstruction  by  the 
prolapsed  uterus.      Tight-lacing  has  received  the  blame, 
and  deservedly  too,  of  a  considerable  proportion  of  female 
ailments,  among  others  of  that  we  are  now  considering. 
Notwithstanding  the  arguments  of  Landau,  and  more  re- 
cently of  Newman,  there  can  be  httle  doubt  that  there  is 
truth  in  the  opinion  expressed  by  Cruveilhier,  and  sup- 
ported by  Dr.  WiUiam  Koberts,  that  tight-lacing  is  com- 
petent to  produce  downward  displacement  of  the  kidney, 
as  it  is  competent  to  produce  vertical  elongation  of  the 
liver,  and  downward  displacement  of  the  pylorus.      But 
acquh-ed  downward  displacement  of  the  kidney  practically 
means   a  moveable  kidney,  for  once  displaced  from  its 

cc 


386  DISEASES    OF    THE    KIDNEY. 

nest  the  kidney  goes  adrift.  In  connection  with  the 
greater  frequency  of  moveable  kidney  in  women,  Becquet 
has  put  forward  a  theory.'  He  states  that  at  each  men- 
struation there  is  a  marked  increase  in  the  size  and  vas- 
cularity of  the  kidneys,  due  probably  to  the  close 
association  of  the  renal  and  ovarian  nerve  plexuses. 
This  periodic  enlargement  he  believes  to  be  a  cause  of 
moveable  kidney,  as  well  as  of  the  lumbar  aching,  so  fre- 
quently complained  of  during  menstruation.  Ebstein  {op. 
cit.)  considers  the  statement  unsupported  by  fact,  but  Dr. 
William  Eoberts  has  recently  recorded  an  interesting  case, 
where  in  a  girl,  aged  seventeen,  a  displaced  kidney  increased 
by  fully  one  half,  and  was  also  more  sensitive  during  the 
two  menstrual  periods  that  she  was  under  observation. 
Also  it  is  a  fact  that  the  symptoms  produced  by  moveable 
kidney  are  usually  more  marked,  indeed  are  sometimes 
present  only  during  menstruation. 

Why  should  the  right  kidney  be  so  much  more  fre- 
quently moveable  than  the  left  ?  Most  probably  for  a 
double  reason,  positive  and  negative.  First,  the  right 
kidney  lies  below  and  behind  the  massive  liver,  while  the 
left  is  in  the  same  relation,  only  to  the  lighter  spleen  and 
more  yielding  stomach.  Second,  the  attachments  of  the 
left  kidney,  as  we  have  already  seen,  are  firmer  than  those 
of  the  right.  The  left  renal  artery  is  shorter  than  the 
right,  and  the  splenic  flexure  of  the  colon  with  which  the 
left  kidney  is  closely  connected,  is  kept  firmly  in  place  by 
the  pleuro- colic  fold. 

Considering  that  the  kidney  is  imbedded  in  fat,  it  is  a 
priori  probable  that  rajnd  emaciation  would  tend  to  pro- 
duce mobility  of  the  kidney,  not  only  indu'ectly  by  reduc- 
ing intra-abdominal  pressure,  but  directly  by  loosening  the 
fatty  bed  of  the  kidney.  This  conclusion  is  fully  justified 
by  facts,  for  example  thirteen  per  cent,   of   Landau's 


MOVEABLE    KIDNEY.  387 

cases  suffered  from  carcinoma.  Any  condition  wliich  in- 
creases the  weight  of  the  kidney  will  tend  to  produce 
mobility,  such  for  example  as  malignant  tumours  of  the 
kidney,  hydro-nephrosis,  calculi,  etc.  Traumatic  causes 
again,  such  as  falls  and  blows,  have  undoubtedly  dis- 
placed the  kidney,  although  in  the  great  majority  of  such 
cases,  some  of  the  predisposing  causes  above  mentioned 
have  been  present. 

141.  Symptoms. — We  have  already  remarked  that  in 
many  cases  of  undoubted  moveable  kidney,  no  inconveni- 
ence has  been  felt,  and  the  condition  has  been  discovered 
only  accidentally  either  by  patient,  or  by  physician. 
Having  been  discovered,  it  is  often  the  source  of  great 
anxiety  to  the  patient,  more  especially  if  the  physician 
gives  an  indefinite  opinion  as  to  its  nature  or  pronounces 
it  to  be  a  malignant  tumour.  And  this  anxiety  as  Landau 
points  out  is  greater  than  it  would  be  with  almost  any 
tumour,  for  every  movement  makes  the  patient  conscious  of 
something  unusual  in  the  abdomen,  and  so  keeps  the  con- 
dition constantly  in  mind.  In  a  proportion  of  cases, 
however,  there  are  most  definite  symptoms,  and  Eb stein 
believes  that  to  this  condition  are  due  many  vague  feelings 
of  abdominal  discomfort  for  which  no  cause  is  discovered 
simply  because  no  thorough  physical  examination  of  the 
abdomen  is  made. 

The  symptom  most  frequently  complained  of  is  the 
'^feeling  of  something  loose  "  in  that  region  of  the  abdomen, 
which  moves  for  example  on  turning  over  in  bed,  with  a 
sense  of  dragging  or  gnawing  at  the  spot,  sometimes 
amounting  to  sharp  pain.  Along  with  the  dull  aching 
localised  pain  there  may  be  distinct  neuralgic  pain  in  the 
course  of  the  lumbar  nerves,  shooting  round  the  abdomen 
to  the  hypogastrium,  and  down  the  thighs.  These  uneasy 
feelings  and  pains  are  as  a  rule  much  increased  during  "the 

CO  2 


388  DISEASES    OF    THE    KIDNEY. 

period  of  menstruation,  indeed,  as  already  stated,  may  be 
present  only  during  these  periods.     They  are  undoubtedly 
due  to  the  dragging  upon  the  renal  plexus  of  nerves  and 
its  connections.      Owing  to  the  mobility  of  the  displaced 
organ,  it  is  rare  to  meet  with  pressure  symptoms,  but 
Landau   quotes   a   case   of  floating  kidney  recorded  by 
Girard,  and  one  of  moveable  kidney  observed  by  himself, 
in  which  cedema  of  the  lower  limbs  was  caused  by  pressure 
on  the  veins,  there  being  in  Girard's  case  an  actual  throm- 
bosis of  the  inferior  cava.      Kollet  {loc.  cit.,  p.  20)  quotes 
a  case  in  which  the  inferior  cava  was  obliterated  by  the 
pressure  of  a  dislocated  kidney.     Cases  of  obstinate  con- 
stipation due  to  pressure  on  the  colon  have  been  recorded, 
e.g.,  by  Kollet,  but  such  cases  must  certainly  be  extremely 
rare,  and  ought  to  be  received  with  caution.      As  regards 
disturbances  of  the  digestive  organs  due  to  moveable  kidney. 
Dr.  William  Eoberts  relates  a  very  instructive  case.     It  is 
that  of  a  gentleman  who  from  the  date  of  a  fall  on  the  ice, 
suffered  from   a   dragging   sensation   in   the   right  loin, 
paroxysmal  diarrhoea,  and  progressive  emaciation.      Ex- 
amination  showed   a  moveable   right  kidney.      He    was 
advised  to  wear  a  belt  and  pad  to  keep  the  organ  in  posi- 
tion.     This  he   did,  with  the  result  that  his  symptoms 
were   completely  relieved   so   long   as   he  persisted,   but 
returned  as  soon  as  he  left  off  the  belt  and  pad.     Some 
evidence  has  been  brought  to  show  that  moveable  kidney 
may  be  a  cause  of  recurrent  icterus  by  pressing  on  the  com- 
mon bile  duct,  and  it  seems  to  be  a  fact  that  recurrent 
icterus  is  common  in  cases  of  moveable  kidney,  but  the 
condition   is   more   probably  due  to  the  chronic  gastro- 
intestinal catarrh  so  frequently  concomitant  with  moveable 
kidney. 

By  far  the  most  important  and  most  serious  of  the 
symptoms  due  to  moveable  kidney,  are  those  of  what  has 


MOVEABLE    KIDNEY.  389 

been  termed  strangulation  of  the  kidney.  Usually  after 
some  sudden  exertion,  but  occasionally  while  at  perfect 
rest  the  patient  is  attacked  with  severe  abdominal  pain, 
and  great  tenderness  in  the  neighbourhood  of  the  kidney, 
frequently  accompanied  by  rigors,  nausea,  and  vomiting. 
If  palpation  can  be  exercised,  the  swollen  and  immovable 
kidney  may  be  felt  displaced  downward  and  forward.  After 
a  few  days,  which  may  extend  to  two  weeks,  the  condition 
invariably  ends  in  recovery,  the  first  sign  of  this  being  a 
copious  discharge  of  urine,  which  may  contain  pus,  and  is 
in  marked  contrast  with  the  urine  passed  during  the 
attack,  which  is  generally  dark  and  scanty.  The  cause  of 
these  attacks  which  occur  repeatedly,  is  not  clear,  but 
according  to  Kollet  it  is  due  either  to  torsion  and  com- 
pression of  the  ureter  with  consequent  hydro-nephrosis,  or 
to  inflammation  and  exudation  in  the  tissues  surrounding 
the  kidney. 

142,  Diagnosis. — Apart  from  the  symptoms  men- 
tioned, most  of  which  will  serve  merely  as  suggestions,  we 
must  depend  for  our  diagnosis  of  moveable  kidney  upon 
the  bimanual  palpation  of  the  organ  practised,  and  recom- 
mended many  years  ago  by  Sir  William  Jenner.  It  may 
be  doubted  if  ever  in  the  normal  subject  we  can  make 
certain  of  actually  palpating  the  kidnej'',  but  as  stated 
above,  those  suffering  from  moveable  kidney  are  as  a  rule 
the  subjects  both  of  emaciation  and  muscular  relaxation. 
In  such  cases  it  is  possible  by  pressing  one  hand  well  into 
the  loin,  to  detect  with  the  other  through  the  abdominal 
wall  a  reniform  tumour,  which  glides  to  and  fro  between 
the  hands.  If  we  are  successful  in  making  out  the  reni- 
form shape,  and  can  also  produce  the  peculiar  nausea  and 
faintness  resulting  from  its  compression,  there  can  be  no 
possibility  of  mistake.  If  not,  however,  it  may  be  con- 
founded with  enlargements  of,  or  tumours  connected  with, 


390  DISEASES    OF    THE    KIDNEY. 

the  liver,  gall-bladder,  stomacli,  spleen,  or  omentum.  The 
surface  and  shape  of  these  will  generally  enable  us  to  de- 
cide, as  also  the  fact,  that  the  displaced  kidney  almost 
invariably  lies  behind  some  coils  of  intestine.  Impacted 
faeces,  especially  in  the  right  colon,  may  simulate  displaced 
Jddney,  but  their  position,  shape,  and  consistency,  will 
assist  in  diagnosis,  and  the  action  of  a  brisk  purge  will 
dissipate  any  doubt  that  may  remain.  Any  difficulty  re- 
garding ovarian  and  uterine  tumours  will  as  a  rule  be  de- 
cided by  careful  vaginal  and  rectal  examination. 

Jenner  would  diagnose  floating  from  moveable  kidney 
by  the  greater  mobility  of  the  former,  idue  to  its  meso- 
nephron.  Experience  does  not  seem  to  confirm  this  cri- 
terion, and  accordingly,  although  the  difference  is  both 
anatomically,  and  as  Newman  has  shown,  (loc.  cit.,  p.  11) 
operatively  important,  we  cannot  clinically  distinguish 
them. 

143.  Prognosis. — Opinions  differ  widely  as  to  the 
importance  and  dangers  of  moveable  kidney,  and  as  fairly 
typical,  we  may  take  those  of  Keppler,  Newman,  and 
Landau.  The  first  considers  the  condition  fraught  with 
so  much  danger,  not  only  to  the  comfort,  but  even  to  the 
life  of  the  patient,  that  he  would  on  its  producing  any 
symptom  whatever,  at  once,  and  notwithstanding  the  ab- 
sence of  any  complication,  extirpate  the  organ  by  an 
abdominal  incision.  Landau  on  the  other  hand  denies 
that  moveable  kidney  has  ever  caused  death,  nay  he  says 
in  a  fair  proportion  of  cases  it  tends  to  a  spontaneous  cure, 
and  that  in  no  case  is  operative  interference,  much  less 
extirpation,  justifiable.  Newman  takes  his  place  between 
these  two  extremes,  and  the  cases  adduced  by  him,  al- 
though few  in  number,  go  far  to  justify  his  position.  In 
many  cases  the  condition  produces  no  symptoms,  and 
therefore  requires  no  treatment,  in  a  considerable  propor- 


MOVEABLE    KIDNEY.  391 

tion  of  the  remainder,  the  symptoms  can  be  relieved  by  sim- 
ple means  to  be  discussed  presently,  in  a  few  cases  severe 
symptoms  occur  which  can  be  relieved  only  by  operative 
measures,  and  even  as  a  last  resort  by  nephrectomy. 

144.  Treatment. — Our  first  object  in  the  treatment 
of  moveable  kidney,  is  to  replace  the  organ  in  position ; 
our  second  to  keep  it  there.  Eeplacement  is  as  a  rule 
easyj  even  where  adhesions  have  formed,  gentle  manipula- 
tion with  the  patient  in  the  horizontal  position  being 
generally  quite  sufficient.  On  resumption  of  the  erect 
posture,  however,  the  organ  at  once  drops  into  its 
abnormal  position.  In  cases  of  traumatic  displace- 
ment, the  patient  should  be  kept  for  a  prolonged  period 
in  the  supine  position,  but  in  these  and  other  cases, 
it  will  be  necessary  to  adopt  means  for  keeping  the 
kidney  in  position.  We  should  in  the  first  place  enjoin 
the  avoidance  as  far  as  possible  of  those  habits  and 
conditions  which  tend  to  produce  mobility  of  the  kid- 
ney. All  violent  exercise  such  as  leaping  or  dancing,  and 
riding,  should  be  strictly  interdicted,  more  especially  in 
a  female  during  the  period  of  menstruation.  Tight-lacing 
should  also  be  forbidden,  and  the  bowels  ought  to  be  regu- 
lated, so  as  to  prevent  straining  at  stool.  Prolonged  rest 
in  the  recumbent  position  after  delivery  has  in  some  cases 
actually  cured  a  previous  existing  mobility  of  the  kidney. 
Oood  food  and  tonic  treatment,  including  the  well  directed 
application  of  massage  and  electricity,  may  in  some 
measure  correct  the  effects  of  emaciation  and  muscular 
relaxation.  When  the  symptoms  above  described  as 
strangulation  of  the  kidney  set  in,  the  patient  should  at 
once  be  put  in  the  horizontal  position,  and  an  attempt 
made  to  replace  the  kidney.  If  the  diagnosis  is  certain, 
Eollet  holds  that  this  attempt  should  be  made  even  ener- 
getically if  necessary.    Should  the  attempt  fail,  the  patient 


392 


DISEASES    0?    THE    KIDNEY. 


may  be  put  in  a  warm  bath,  and  then  a  second  attempt 
made.  Poultices  and  leeches  or  cupping  may  be  applied 
to  relieve  the  pain  and  congestion,  and  a  full  dose  of 
morphia  should  be  administered.  Eeplacement  of  the 
kidney  will  certainly  be  possible  within  a  few  days,  when 
the  symptoms  will  subside. 

To  keep  the  kidney  in  position  when  the  patient  gets  up, 
is  an  extremely  difficult  matter,  but  in  many  cases  the 
symptoms  will  be  reheved  if  we  can  keep  it  still.  Many 
complicated  mechanisms  have  been  devised  for  this  pur- 
pose, the  success  of  which  is  in  direct  proportion  to  the 
degree  in  which  they  supply  an  artificial  abdominal  wall. 
Landau  recommends  a  well- applied  abdominal  bandage 
made  of  drill  or  flannel,  elastic  at  the  sides,  and  provided 
with  shoulder  straps  to  prevent  its  slipping  down.  Better 
than  this,  however,  he  considers,  is  a  peculiar  form  of 
'  corset,'  the  principle  of  which  is  precisely  the  opposite  of 
that  usually  worn.  It  must  not  constrict  the  lower 
thoracic  region,  and  it  should  reach  in  the  middle  line  to 
the  pubes  (the  middle  steels  being  jointed  if  necessary), 
and  at  the  sides  to  Poupart's  ligament.  Over  the  region 
of  the  kidney  in  place  of  the  usual  pad  should  be  placed  a 
concave  tin  plate. 

In  those  cases  where  for  some  reason  mechanical 
support  cannot  be  borne,  or  fails  to  relieve,  and  where  the 
symptoms  are  so  severe  as  to  incapacitate  for  the  ordinary 
duties  of  life,  operative  interference  is  necessary  and  justifi- 
able. This  will  take  the  form  of  nephroraphy,  or  even  as 
a  last  resort  nephrectomy.  For  a  full  account  of  the  first 
operation  which  consists  in  making  an  incision  over  the 
kidney  in  the  loin,  and  stitching  it  into  the  wound,  we 
must  refer  the  reader  to  Dr.  Newman's  monograi)h  on 
malpositions  of  the  kidney,  where  also  will  be  found  a 
discussion  of  the  circumstances  in  which  nephrectomy  is 
or  is  not  justifiable  for  moveable  kidney. 


ABNORMAL    FORMS    AND    POSITIONS.  393 


II.  ABNORMALITIES  IN  FORM  AND  NUMBER. 

145.  These  abnormalities  are  almost  without  exception 
congenita],  and  accordingly  the  same  remark  applies  to 
them  as  to  the  fixed  malpositions  of  the  kidney,  that  they 
are  more  of  anatomical  curiosities  than  conditions  clinically 
important. 

1.  Abnormalities  in  Form. — The  two  principal  condi- 
tions of  the  kidney  falling  under  this  head,  are  the  lobu- 
lated  and  the  horse-shoe  kidney.  The  lobulated  kidney  is 
the  result  of  the  persistence  of  the  foetal  lobulation  which 
we  see  permanent  in  many  animals,  and  which  is  the  ex- 
ternal indication  of  what  is  evident  internally,  that  the 
kidney  consists  not  of  one  gland,  but  of  a  cluster  opening 
into  a  common  duct.  The  horse-shoe  kidney  is  produced  by 
the  union  of  the  two  kidneys  by  means  of  a  transverse  por- 
tion lying  in  front  of  the  vertebrse.  The  concavity  of  the 
horse-shoe  lies  in  the  great  majority  of  instances  upwards, 
the  transverse  portion  joining  the  inferior  extremities  of 
the  vertical  portions,  and  having  in  front  of  it  the  two 
ureters,  behind  it  the  aorta  and  inferior  vena  cava.  Such 
malformed  kidneys  are  not  unfrequently  also  misplaced, 
and  as  a  rule  downwards.  The  principal  danger  connected 
with  them  is,  as  in  the  case  of  fixed  malposition,  mistaken 
diagnosis,  and  the  anxiety  and  active  treatment  the 
patient  may  in  consequence  have  to  undergo.  Cases  are, 
however,  quoted  by  Ebstein,  which  show  that  the  posses- 
sion of  a  horse-shoe  kidney  is  not  quite  an  indifferent 
matter.  In  one  case,  thrombosis  of  the  great  veins  was 
caused  by  a  congested  horse-shoe  kidney,  in  another  com- 
pression of  the  ureters  during  pregnancy  caused  pyelitis 
and  death. 

2.  Abnormalities   in    Number. — From   what   has   been 


394  DISEASES    OF    THE    KIDNEY. 

already  stated  as  to  the  kidney  being  really  an  agglomera- 
tion of  many  glands,  it  is  not  to  be  wondered  at  that  we 
occasionally  meet  with  small  sujjernumerary  kidneys  having 
separate  ducts.  A  far  more  important  variety  is  the 
solitary  kidney,  which  in  the  majority  of  instances  is  a  con- 
genital, but  may  be  an  acquired  condition.  Of  twenty- 
nine  cases  of  solitary  kidney  collected  by  Dr.  W.  Koberts, 
twenty -two  occurred  in  males,  six  in  females,  and  in  one 
the  sex  was  not  stated.  In  sixteen  the  solitary  kidney 
was  on  the  right  side,  in  twelve  on  the  left,  in  one  the  side 
was  not  stated.  In  nineteen  cases  the  condition  was  con- 
genital, in  three  it  was  acquired,  that  is  resulted  from 
destruction  of  the  other  kidney,  and  in  seven  it  was  doubt- 
ful. It  will  be  seen,  therefore,  that  soHtary  kidney  is 
much  more  frequent  in  males  than  in  females,  and  that 
the  left  kidney  is  more  frequently  absent  than  the  right, 
agreeing  in  both  respects  with  fixed  congenital  malposi- 
tion of  the  kidney.  In  congenital  absence  of  a  kidney,  it 
is  usual  to  find  no  trace  of  its  ureter  or  vessels,  but 
Buchhammer's  cases  [Arch,  filr  Anat.  und  Physiol.,  1879) 
show  that  it  is  common  for  the  solitary  kidney  to  possess 
two  ureters  and  two  sets  of  vessels,  the  ureters  crossing 
each  other  to  open  normally  at  the  base  of  the  bladder. 
Where  owing  to  disease,  one  kidney  has  been  destroyed, 
we  usually  find  its  ureter  remaining,  and  frequently  some 
trace  of  the  organ  itself.  In  both  cases  the  single  kidney 
is  hypertrophied,  and  so  long  as  matters  go  smoothly, 
seems  perfectly  competent  to  carry  on  the  double  duty  laid 
upon  it.  The  danger  of  the  condition,  however,  and  this 
is  to  be  borne  in  mind  in  considering  nephrectomy,  is 
shown  by  the  fact  that  in  twenty-four  cases,  death  was  in 
ten  cases  directly  due  to  there  being  but  one  kidney,  a 
renal  calculus  having  developed,  while  in  two  other  cases 
death  was  caused  by  the  pressure  of  a  cancerous  tumour 


ABNOBMAL    FOKMS   AND    POSITIONS.  395 

on  the  single  ureter.  Nephrotomy  and  nephrectomy  have 
now  mainly  through  the  results  of  Enowsley  Thornton, 
Henry  Morris,  Beck  and  others  in  this  country,  become  not 
only  recognized  but  highly  successful  operations.  In  both 
operations,  however,  it  is  well  for  operators  to  remember 
that  rare  as  the  condition  is,  any  given  case  may  be  one 
of  solitary  kidney.  By  careful  physical  examination,  and 
by  compression  of  one  ureter,  with  Davy's  Eectal  Lever, 
some  assurance  will  be  acquired  as  to  the  presence,  and 
also  the  secreting  powers,  of  a  second  kidney. 


396  DISEASES    OF    THE    KIDNEY. 


CHAPTER  IX. 

Diabetes  Insipidus.     Diabetes  Mellitus.     Anuria. 

Diabetes  Insipidus. 

146.  Under  the  terms  diuresis,  diabetes  insipidus, 
polyuria,  and  polydipsia,  writers  have  described  a  cer- 
tain morbid  condition  of  the  system  characterised  by  the 
excessive  and  persistent  discharge  of  urine  of  low  specific 
gravity — containing,  however,  neither  sugar  nor  albumin. 
Most  authors  apply  either  of  the  above  terms  to  denote 
this  urinary  superflux,  without  reference  to  the  quanti- 
tative relationship  that  may  exist  in  individual  cases  be- 
tween the  urinary  water  and  solids.  Others,  of  whom 
Willis  seems  to  have  been  the  first,  have  attempted  to 
form  a  classification  on  this  basis.  Thus  Willis  divided 
cases  of  diabetes  insipidus  into  three  groups  : — (1)  those 
attended  with  excessive  discharge  of  aqueous  urine,  in 
which  the  solid  matters  are  deficient — hydruria  ;  (2)  those 
attended  with  a  copious  discharge  of  urine  characterised 
by  a  deficiency  of  urea — anazoUirla ;  and  (3)  those  in 
which  the  excessive  discharge  of  urine  was  attended  with 
a  superabundance  of  urea — azotiiria.  Parkes  also  sup- 
ported the  view  that  diabetes  insipidus  was  to  be  found 
existing  under  three  difi'erent  conditions: — (1)  in  cases 
where  there  is  no  increase  or  decrease  of  tissue  metamor- 
phosis ;  (2)  in  cases  where  there  is  a  decided  decrease  of 
tissue  metamorphosis  ;  (3)  cases  where  there  is  evidence 
of  increased  tissue  metamorphosis,  as  shown  by  the  in- 
crease of  some  of  the  urinary  solids.     For  this  latter  class 


DIABETES    INSIPIDUS.  397 

of  cases  Professor  Parkes  thinks  the  term  polyuria  prefer- 
able to  that  of  azoturia,  which  only  expresses  the  fact  of 
the  urea  being  increased ;  whereas  in  the  cases  quoted  by 
him  the  fixed  salts,  as  chlorides,  sulphates,  and  phos- 
phates, were  also  present  in  abnormal  quantities.  Lastly, 
Dr.  Tessier  of  Lyons  has  recently  recorded  a  series  of 
cases  closely  resembling  saccharine  diabetes,  in  the  in- 
creased discharge  of  urine,  the  thirst,  the  neuralgic  and 
rheumatic  pains,  the  wasting,  and  the  secondary  lung 
complications,  only  that  no  trace  of  sugar  could  be  found 
in  the  urine,  and  that  the  constant  phenomenon  was  a 
very  considerable  increase  in  the  quantity  of  phosphoric 
acid  excreted  (fifteen  to  twenty  grammes  of  earthy  phos- 
phates in  twenty-four  hours).  For  the  purpose  of  con- 
venience it  is  better  at  present  to  construct  a  classification 
which  has  reference,  first  to  the  excessive  excretion  of 
water  by  the  kidneys,  and  secondly  to  the  increase  of 
solid  matter  by  the  same  channel.  For  this  purpose  the 
terms  suggested  by  Willis  and  Parkes  can  both  be  utilized, 
the  former,  Hydruria,  referring  to  cases  attended  with  ex- 
cessive discharge  of  aqueous  urine,  with  or  without  de- 
crease in  the  amount  of  the  solid  constituents  of  the 
urine.  Polyoma,  as  relating  to  cases  in  which  the  urea, 
singly,  or  else  together  with  the  other  urinary  constitu- 
ents, is  excreted  in  abnormal  quantities."^ 

147.  Symptoms. — 1.  Hydruria  is  characterised  by  a 
copious  and  persistent  discharge  of  pale  limpid  urine  of 
low  specific  gravity.  The  amount  of  water  discharged  in 
the  twenty-four  hours  is  enormously  increased,  taking 
two-and-a-half  pints  as  the  normal  daily  excretion  of  a 
healthy  adult.  Trousseau  {op.  cit.,  p.  530)  records  a  case 
in  which  the  urine  discharged  amounted  to  fifty-six  pints. 
This,  of  course,  is  exceptional,  and  as  a  general  average 
the  quantity  ranges  between  ten  and  fifteen  pints.     Owing 


398  DISEASES    OF    THE    KIDNEY. 

to  the  difficulty  of  collecting  the  urine  in  children,  it  is 
difficult  to  form  an  appreciable  idea  of  the  amount  they 
pass  when  subject  to  the  disease  ;  but  to  judge  from  the 
constant  diuresis  going  on  it  musfe  be  very  great.  The 
older  writers  thought  that  the  amount  of  water  discharged 
by  the  kidneys  in  this  disease  was  in  excess  of  that  in- 
gested. They,  however,  overlooked  the  fact  that  a  con- 
siderable amount  of  water  is  taken  into  the  body  with  the 
soUd  constituents  of  the  food.  The  specific  gravity  is 
extremely  low.  In  severe  cases,  it  has  been  noticed  as 
low  as  1-0005,  the  general  range,  however,  is  between 
1-003  and  1-004.  The  solid  matter  discharged  does  not, 
however,  show  any  marked  reduction ;  indeed,  if  the  appe- 
tite is  good,  there  is  usually  some  increase,  especially 
when  much  fluid  nourishment  such  as  beef  tea,  milk,  etc., 
is  taken,  to  support  the  patient  and  relieve  thirst.  Thus 
a  patient  passing  9000  c.c.  of  urine  in  the  twenty-four 
hours  having  a  specific  gravity  of  1-003,  would,  accord- 
ing to  Trapp's  formula,  be  eliminating  by  the  kidneys 
54  grammes  of  solid  matter,  an  amount  closely  ap- 
proximating to  the  normal.  In  a  patient  of  my  own 
who,  however,  took  considerable  quantities  of  beef  tea  and 
milk,  the  figures  were — amount  of  urine  9500  c.c,  specific 
gravity  1-004,  sohds  76  grammes,  or  about  20  grammes 
more  than  the  normal,  showing  that  the  eliminating 
powers  of  the  kidneys  are  not  diminished  in  this  disorder. 
The  urea  is  not  diminished,  though  stated  by  Willis  to  be 
so,  in  the  hydruria  of  young  childi-en. 

Sir  Andrew  Clark  has  recently  drawn  attention  to 
some  cases  in  which,  with  a  urine  of  very  low  specific 
gravity,  there  was  a  very  considerable  decrease  in  the 
amount  of  urea  excreted ;  there  is,  however,  no  superflux 
of  urinary  water,  in  fact  the  amount  of  urine  may  be  de- 
creased.    Such  a  urine  as  that  described  by  Sir  Andrew 


DIABETES   INSIPIDUS,  399 

Clark,  is  also  passed  by  patients  suffering  from  myxoedema. 
Sir  Andrew  Clark  believes   in   these   cases  the   kidneys 
fail   in    their    eliminating    function    (renal   inadequacy), 
whilst  I  have  suggested  that  the  deficiency  of  the  urea 
is  due  to  defective  tissue  metabolism   generally.      They 
cannot,  however,  be  regarded  as  in   any  way  allied  to 
diabetes  insipidus.     Uric  acid  is  said  to  be  decreased  in 
hydruric  urines.     This  I  doubt ;    the  apparent  deficiency 
being  caused,  I  believe,  by  the  fact,  that  the  urine  is  too 
dilute  to  allow  of  uric  acid  crystallizing  out,  when  acidu- 
lated ;    by  concentrating  these  urines  to  a  specific  gravity 
of  1-020,  and  then  adding   acid,   an   abundant  yield  of 
crystals  will   generally   be    obtained.      Phosphoric   acid, 
especially  that  in  combination  with  the  earthy  salts,  is 
generally,  but  not  invariably,  increased.      When  an  in- 
crease is  noted,  it  may  be  attributed,  I  think,  to  increased 
ingestion,  as  from  beef  tea  and  milk,  and  to  the  washing 
out  of  the  tissues  by  the  drainage  going  on  through  the 
body.     In  cases  directly  the  result  of  intra-cranial  disease, 
the   increase   of  the   earthy  phosphates  may  be   due  to 
metabolism  of  the  nervous  centres.     The   chlorides  and 
sulphates  may  also  be  increased,  both  from  increased  in- 
gestion, and  from  washing  out  of  the  tissues.   The  reaction 
of  the   urine  is   usually  neutral,  or   feebly   acid,   rarely 
alkaline,  and  then  only  temporarily  so.     The  colour  when 
viewed  by  transmitted  light,  is  of  a  pale  green  with  a 
bluish  tint  (sea-green).     The  urine  often  contains  inosite, 
sometimes  albumin,  which  occasionally  becomes  abundant, 
and  often  traces  of  sugar.     Beyond  the  profuse  discharge 
of  aqueous  urine  and  the  thirst  it  occasions,  there  inay  be 
no  other  symptoms,  and  it  may  be  compatible  with  fair 
bodily  health,  and  even  long  life.     Thus  cases  are  recorded 
of  the  continuance  of  the  disease  for  twenty- four,  thirty- 
seven  and  thirty-nine  years,  in  persons  who  during  that 


400 


DISEASES    OF    THE    KEDNEY. 


time  remained  iu  fairly  good  liealth.  As  a  rule,  however, 
hydruric  patients,  though  suffering  from  no  definite  dis- 
ease, have  only  poor  health.  They  are  chilly,  and  sudden 
changes  from  temperate  weather  to  cold  increase  then* 
diuretic  tendencies.  Though  the  bowels  are  usually  con- 
stipated, diarrhoea  is  easily  provoked.  The  appetite  is 
capricious,  a  sinking,  gnawing  sensation  being  complained 
of  rather  than  the  ravenous  hunger  of  saccharine  diabetes. 
As  a  rule  the  ingestion  of  alcohol  is  followed  by  an  in- 
crease of  the  urinary  flux,  and  small  quantities  act  on 
the  nervous  system ;  on  the  other  hand  cases  have  been 
recorded  in  which  enormous  quantities  of  alcohol  have 
been  swallowed ;  Trousseau  mentions  twenty  bottles  of 
wine  at  a  sitting,  without  producing  any  effect. 

2.  Polyuria  is  characterised  by  the  discharge  of  urine 
increased  as  to  the  quantity  of  its  aqueous  and  sohd  con- 
stituents. The  amount  of  water  passed  in  the  twenty-four 
hours,  however,  never  approaches  the  enormous  quantity 
discharged  in  hydruric  cases,  though  the  sohd  matters 
may  be  increased  twice  or  even  three  times  in  amount. 
The  quantity  of  urine  passed  iu  the  twenty-four  hours 
averages  about  2500  to  3500  c.c,  and  the  specific  gravity 
ranges  from  1-010  to  1-025.  The  following  table  -will 
show  the  chief  characters  of  the  urine  in  polyuria,  as  com- 
pared with  the  normal  secretion. 


Age. 

35 

16 

25 
27 
37 
20 

Wkight. 

Quantity. 

Spfcific 
Gravity. 

1-020 

1010 
1-015 
1022 
1-018 

Till6 

Solids. 
58  grms. 

Phosphc- 
ETC  Acid. 

Urea. 

Normal 

list. 

9  St 

9  St. 
8st.  71b. 
12st.71b. 

9  St. 

1400  c.c. 

3900  c.c. 
2300  „ 
1500   ,, 
23(10   „ 
3825   „ 

2-8  grms. 

33  grms. 

Case  1 
Case  2 
Case  3 
Case  4 
Case  5 

76  grms. 
69      „ 

^^      » 
83      „ 

122 

5-2  grms. 
7-S     „ 
5-2     „ 
4-6      „ 
^7     „ 

51  grms. 
33     „ 
41     „ 

69     „ 

87     „ 

In  all  these  cases  the  amount  of  soHd  matter  excreted  is 


DIABETES    INSIPIDUS.  401 

in  excess  of  the  uormal,  and  in  some  considerably  so.  In 
cases  two  and  three,  however,  the  increase  is  in  the 
amount  of  phosphoric  acid  excreted,  the  urea  in  Case  2 
being  normal,  and  in  Case  3  only  slightly  increased.  These 
two  cases,  therefore,  resemble  very  closely  those  described 
by  Tessier  under  the  term  "  phosphatic  diabetes."  In  the 
others,  however,  the  urea  as  well  as  the  phosphoric  acid 
are  both  considerably  increased,  and  resemble  the  cases  of 
azoturia,  related  by  Prout  and  Willis,  and  those  of  Vogel, 
quoted  by  Parkes  (o^j.  cit.,  p.  365).  The  urines  passed  by 
these  patients  are  usually  acid  in  reaction,  and  are  free 
from  albumin  and  sugar,  traces  of  the  latter,  however, 
may  occasionally  appear.  Although  the  amount  of  urine 
is  generally  in  excess  of  the  normal,  still  in  some  cases  no 
suc'h  increase  is  noted,  in  these  cases,  however,  the  specific 
gravity  is  enormously  increased,  thus  I  recently  saw  an 
instance  in  which  the  urine  averaged  daily  about  1300  c. c, 
with  a  specific  gravity  of  1*034,  making  the  solid  matters 
excreted  about  88  grms. 

The  symptoms  attendant  on  polyuria  are  debility  and 
languor,  loss  of  weight,  neuralgic  and  rheumatic  pains, 
chiefly  in  the  loins  and  down  the  thighs,  and  a  moderate 
degree  of  thirst.  Tessier  observes  that  in  those  cases 
marked  by  an  excessive  elimination  of  phosphates,  cataract 
sometimes  ensues.  I  have,  however,  never  seen  an  in- 
stance, though  I  have  seen  patients  suft'ering  from  boils, 
a  circumstance  that  Tessier  also  insists  on,  as  showing  the 
relationship  of  the  disorder  to  saccharine  diabetes  into 
which  it  somstimes  merges. 

148.  "Etiology.— Hydruria. — According  to  Lancereaux 
and  Eoberts  the  disease  occurs  twice  as  frequently  in  men 
as  in  women.  It  is  slightly  more  prevalent  in  the  first 
twenty  years  of  life  than  in  the  second,  whilst  after  middle 
age  it  is  comparatively  rare  for  the  disease  to  originate. 

DD 


402  DISEASES    OF    THE    KIDNEY. 

The  following  are  the  chief  causes  to  which  the  disease 
has  been  attributed,  in  cases  which  are  not  distinctly  of 
cerebral  origin.  Hereditary  influences,  sudden  chilling  of 
the  body  when  heated,  sunstroke,  alcoholic  excesses, 
especially  in  persons  already  suffering  from  alcoholism. 
Insipid  diabetes  in  young  children  has  in  some  instances 
been  traced  to  the  j)arents  allowing  them  to  drink  sj^irits, 
a  practice  not  uncommon  among  some  of  the  drunken 
mothers  of  the  lower  orders.  Violent  mental  emotions,  and 
hysterical  conditions,  violent  muscular  exertions,  severe 
illness,  especially  after  fevers,  malarial  cachexia,  have  all 
been  assigned  as  causes,  though  as  Dickinson  very  fitly 
remarks,  these  supposed  causes  may  be  no  more  than 
chance  antecedents.  When  the  disease  can  be  distinctly 
referred  to  the  nervous  system,  the  exciting  cause  is  then 
usually  traced  with  greater  positiveness.  Thus  injuries 
of  the  head ;  tubercular,  and  epidemic  cerebro- spinal 
meningitis;  intra-cranial  growths,  syx^hilitic  or  tubercular; 
pressure  on  the  renal  nerves  by  abdominal  tumours  ;  irri- 
tation of  the  pneumogastric  by  growth  of  intra-thoracic 
aneurisms,  etc.  (see  cases  in  Lancet,  Feb.  26,  1876,  by 
author) ,  have  been  found  to  give  rise  to  hydruria.  Tem- 
porary hydruria  may  occur  during  pregnancy,  especially 
in  the  later  months,  and  disappears  after  delivery.  It 
often  occurs  as  a  fleeting  symptom  in  hysterical  and 
emotional  women. 

Polyuria. — The  etiological  conditions  which  give  rise  to 
this  form  of  insipid  diabetes  are  still  to  be  elucidated.  They 
depend  no  doubt  upon  some  profound  disturbance  of  the 
nervous  system,  the  result  of  which  is  to  cause  increased 
tissue  metabohsm  (p.  78).  "When  both  urea  and  phos- 
phoric acid  are  increased,  then  the  increased  metabolism 
probably  affects  the  system  generally;  when,  however, 
the  phosphoric  acid  is  relatively  in  excess  of  the  urea,  it 


DIABETES    INSIPIDUS.  403 

points  iindoubtedly  to  disintegration  of  nervous  matter. 
Of  Dr.  Tessier's  cases,  the  majority  were  males  between 
the  ages  of  20  and  40.  In  eight  cases  that  have  been 
under  my  observation  all  were  males,  the  oldest  was  48 
years  of  age,  the  youngest  16,  the  average  age  being 
22  years.  In  five  of  the  eight  cases  the  disease  came  on 
insidiously,  and  no  definite  cause  could  be  assigned  for  it, 
whilst  three  were  decidedly  tubercular,  and  one  developed 
phthisis  whilst  under  observation. 

149.  Pathology. — Hydruria. — Experimentally  it  has 
been  proved  that  puncture  of  the  floor  of  the  fourth  ven- 
tricle, a  little  above  the  orifices  of  the  pneumogastric  and 
auditory  nerves,  gives  rise  to  a  superabundant  flow  of 
urine,  which  is  sometimes  albuminous.  Irritation  of  the 
middle  lobe  of  the  cerebellum  has  also  the  same  effect ; 
whilst  section  of  the  splanchnics,  and  irritation  of  the 
pneumogastric,  are  both  followed  by  a  copious  secretion 
of  aqueous  urine.  Consequently  pathologists  have  sought 
for  lesions  in  these  regions,  in  order  to  explain  the  pheno- 
mena of  diabetes  insipidus,  and  as  a  matter  of  fact,  such 
lesions  have  been  discovered  in  connection  with  the  disease. 
With  regard  to  the  intra-cranial  lesions  it  is  not  necessary 
for  the  primary  pathological  change  to  occur  exactly  at 
the  floor  of  the  fourth  ventricle,  their  effect,  no  doubt, 
may  be  propagated  to  it.  Thus  in  the  case  of  a  patient 
who  died  with  marked  cerebral  symptoms,  and  had  pro- 
fuse hydruria  for  some  weeks  before  his  death,  at  the 
post-mortem  examination,  a  small  syphilitic  gumma  about 
half  the  size  of  a  small  hazel  nut,  was  found  situated  in 
the  middle  line,  under  the  floor  of  the  third  ventricle, 
obstructing  some  of  the  vessels  at  the  base,  whilst  there 
was  some  softening  of  the  brain  substance  in  that  region. 
So  also  with  injuries  to  the  head,  since  the  effect  of  a 
blow  may  be  transmitted  to  the  basal  and  posterior  por- 

dd2 


404  DISEASES    OF    THE    KIDNEY. 

tion  of  the  brain  either  directly  or  by  contre-coup.  The 
kidneys  have  been  found  but  httle  changed  structurally. 
They  are  usually  somewhat  enlarged,  and  Dickinson  has 
observed  punctiform  injection  of  the  cortical  tissue.  Sac- 
cular dilatation  of  the  kidneys  has  been  described  as  a  post- 
mortem condition,  but  these  cases  were  probably  ones 
of  ordinary  hydro-nephrosis.  Other  renal  changes  have 
also  been  described ;  but  in  these  some  other  morbid  con- 
ditions co-existed  in  the  urinary  passages  sufficient  to 
account  for  them. 

Polyuria. — No  post-mortem  examination  has  ever,  as 
far  as  I  have  been  able  to  ascertain,  been  made  on  one 
of  these  cases.  In  a  patient  under  my  care  the  only  posi- 
tive pathological  lesion  that  could  be  discovered  during 
life,  was  pulmonary  consumption,  and  which  might  pro- 
bably account  for  the  increase  of  phosphoric  acid  in  the 
urine ;  since  Marcet  has  shown  from  analysis  of  pul- 
monary tissue  in  consumption,  that  a  considerable  reduc- 
tion of  phosphoric  acid  and  potash  takes  place,  both  in 
the  insoluble  tissue  and  nutritive  material,  as  compared 
with  healthy  lung.  Those  cases,  however,  in  which  both 
urea  and  phosphoric  acid  are  increased,  are  probably  the 
result  of  an  increased  intra- molecular  action  of  the  cells 
throughout  the  body,  whereby  they  make  use  of  the  oxy- 
gen stored  up  in  them,  and  so  give  rise  to  increased  tissue 
metabolism.  This  condition  may  be  transient,  and  pro- 
duced by  excess  of  food,  especially  when  highly  nitro- 
genized,  nervous  influences,  or  temporary  disturbance  of 
function. 

150.  Diagnosis. — In  hydro-nephrosis  considerable  dis- 
charge of  a  highly  aqueous  urine  takes  place.  This  dis- 
ease, however,  can  be  distinguished  from  insipid  diabetes 
by  the  fact  that,  in  hydi-o -nephrosis,  the  diuresis  is  more 
or  less  intermittent.     In  sacculated  kidney,  the  urine  is 


DIABETES    INSIPIDUS.  405 

abundant,  and  of  low  specific  gravity,  but  the  amount 
never  approaches  to  anything  like  what  we  meet  with  in 
hydruria.  Nor  is  it  possible  in  the  ordinary  run  of  cases 
to  confound  diabetes  insipidus,  even  when  the  urine  con- 
tains albumin,  with  the  diuresis  of  granular  kidney  ;  for 
putting  aside  the  absence  of  cardio-vascular  changes  in 
the  former  condition,  the  urine  of  chronic  Bright's  dis- 
ease falls  short  of  that  passed  in  hydruria,  nor  does  the 
specific  gravity  ever  fall  so  low.  But  there  are  some 
anomalous  cases  in  which  the  diagnosis  is  at  first  difficult ; 
thus  a  hospital  patient  who  had  slight  albuminuria  and 
some  degree  of  diuresis,  and  had  suffered  from  repeated 
attacks  of  ague,  after  treatment  with  large  doses  of 
quinine  the  albuminuria  ceased,  but  at  the  same  time  the 
diuresis  enormously  increased,  and  the  disorder  assumed 
the  form  of  insipid  diabetes,  and  which  was  subsequently 
reduced  by  the  administration  of  ergot,  given  with  quinine. 
The  absence  of  sugar  both  in  hydruric  and  polyuric  cases 
distinguishes  them  from  saccharine  diabetes.  The  great  in- 
crease of  the  urinary  solids  in  polyuria,  and  the  absence  of  al- 
bumin prevents  confusion  with  regard  to  any  form  of  chronic 
renal  disease.  Temporary  albuminuria  (see  functional  al- 
buminuria), however,  is  not  infrequently  attended  with  an 
increased  excretion  of  urea,  resembling  what  is  noticed  in 
X^olyuria ;  both  conditions  being  probably  allied  and  due 
to  the  same  cause,  viz.,  a  disturbance  of  the  nitrogenous 
equilibrium,  from  increased  metabolism,  caused  probably 
by  over- stimulation — by  a  too  highly  nitrogenized  diet. 

151.  Prognosis,  Course,  etc. — Hydruria.  It  has 
been  already  stated  that  the  prolonged  discharge  of  a  highly 
aqueous  urine  in  excessive  amounts,  may  not  affect  the 
bodily  health,  and  is  not  incompatible  with  length  of  days. 
Even  in  the  most  unfavourable  cases,  as  those  dependent 
upon  lesions  of  the  encephalon,  improvement  often  takes 


406  DISEASES    OF    THE    KIDNEY. 

place  under  treatment.  Absolute  cure  of  the  disease  is, 
however,  rare,  though  the  diuresis  may  be  controlled.  In 
some  instances  the  disease  has  been  arrested  by  the  onset 
of  some  acute  disease.  Death  when  it  occurs  is  usually 
by  some  intercurrent  affection,  but  in  some  instances 
uremic  coma  supervenes,  as  if  the  function  of  the  kidney 
had  undergone  suspension. 

Polyuria. — The  long- continued  discharge  of  the  urinary 
sohds  in  excessive  amounts  must  always  be  regarded  as  a 
grave  circumstance,  and  is  often  the  prelude  of.  some 
serious  constitutional  disturbance,  of  cancer,  tubercle  and 
constitutional  syphilis.  In  the  more  pronounced  form 
they  may  run  a  distinct  course,  resembling  saccharine 
diabetes,  but  without  sugar,  and  terminate  either  with 
marked  nervous  disorder,  or  in  phthisis ;  or  after  a  while 
sugar  may  appear  in  the  urine,  and  the  case  becomes  one 
of  true  saccharine  diabetes. 

152.  Treatment. — Since  Hydruria  depends  on  the  in- 
terruption of  innervation  by  the  vaso-motor  tracts  leading 
to  dilation  of  the  renal  arteries,  and  consequently  giving  rise 
to  increased  capillary  pressure,  it  has  been  sought  to  restore 
the  arterial  tonicity  by  means  of  special  remedies.  Of 
these  ergot  of  late  years  has  been  chiefly  used,  and  several 
instances  of  its  successful  employment  have  been  recorded. 
In  some  cases  its  administration  is  said  to  have  been  fol- 
lowed by  a  cure.  I  have  never  seen  myself  such  a 
favourable  result,  but  there  can  be  no  doubt  that  in  some 
cases  it  does  diminish  the  hydruria,  both  during  the  time 
the  drug  is  taken,  and  some  time  after.  In  some  cases  it 
has  failed  to  do  good,  whilst  in  some  it  has  done  positive 
harm.  Valerian  too  is  a  remedy  that  has  been  largely 
employed  for  the  treatment  of  insipid  diabetes,  and  in 
cases  where  the  hydruria  is  a  fleeting  symptom,  rather 
than  an  established  disease,  it  undoubtedly  does  good  when 


DIABETES   INSIPIDUS.  407 

given  in  large  doses,  such  as  half  an  ounce  of  the  tinc- 
ture three  times  a  day,  valerianate  of  zinc  in  three  grain 
doses  may  be  given  advantageously  at  the  same  time. 
Nux  vomica  or  its  alkaloid,  strychnia,  is  also  a  useful 
adjuvant,  perhaps  helping  to  restore  the  arterial  tonicity. 
Belladonna  has  been  given  with  the  view  of  causing  con- 
traction of  the  vessels,  but  it  should  be  administered  with 
caution,  as  instances  have  been  recorded  in  which  hydruric 
patients  have  shown  a  marked  susceptibility  to  its  in- 
fluence. In  no  case,  however,  should  the  indications  for 
special  treatment  be  overlooked,  that  is  to  say,  if  there  is 
any  definite  evidence  that  the  disorder  has  originated  from 
or  is  connected  with  any  special  cause,  such  as  traumatic 
lesion  of  the  brain  substance,  intra-cranial  growths,  con- 
stitutional taints,  such  as  scrofula,  syphilis  or  malaria, 
alcoholism,  etc.  In  these  cases  we  must  apply  special 
remedies  before  we  can  hope  to  restrain  the  diuresis 
by  medicines  like  ergot,  valerian,  etc.  Thus,  in  the 
case  already  alluded  to  of  profuse  hydruria,  following 
on  albuminuria,  in  a  malarial  subject,  quinine  was 
given  in  large  doses  before,  and  during  the  administra- 
tion of  ergot,  and  the  relief  of  the  diuresis  was,  I  am 
convinced,  as  much  due  to  the  one  as  the  other.  And  in 
children  improvement  often  follows  the  administration  of 
cod-liver  oil  and  syrup  of  the  iodide  of  iron.  With  regard 
to  the  dietetic  and  hygienic  treatment.  Food  should  be 
liberally  given,  three  substantial  meals  daily,  whilst  any 
craving  and  sinking  between  meals  should  be  promptly 
relieved  by  some  minor  meal.  The  diet  should  be  a  mixed 
one,  with  a  liberal  supply  of  fatty  food.  The  patient 
should  be  allowed  to  relieve  his  thirst  at  pleasure.  When 
undue  restraint  has  been  practised  on  patients  in  this  res- 
pect, serious  disturbance  of  the  bodily  functions  results.  In 
cold  weather  the  fluids  should  be  warmed,  the  ingestion  of 


408  DISEASES    OF    THE    KIDNEY. 

large  quantities  of  water  at  a  temperature  little  above 
freezing  point  must  abstract  a  large  amount  of  beat  from 
the  body,  and  as  these  patients  suffer  much  from  depressed 
temperature  it  is  a  point  worth  paying  attention  to,  since 
the  patients  themselves  prefer  cold  drinks  because  they 
are  more  grateful  to  the  parched  tongue  and  palate.  The 
drink  too  should  be  thickened,  either  with  barley  or  better 
still  with  oatmeal.  A  handful  of  raw  oatmeal  stirred  into 
a  quart  of  boiling  water  with  one  lemon  sliced  into  it  forms 
a  most  grateful  and  thirst- quenching  drink.  The  clothing 
should  be  warm,  the  vests,  drawers  or  stockings  being  all 
of  wool.  When  it  is  possible,  sufferers  from  this  disorder 
should  select  a  locality,  with  a  dry  sub- soil,  with  a  South  or 
South-west  aspect,  to  reside  in,  whilst  if  they  are  in  a  posi- 
tion to  afford  it,  they  should  pass  their  winters  in  Southern 
latitudes.  The  employment  of  the  Eussian  vapour  bath, 
and  sea- water  douches,  either  natural  or  artificial,  give 
great  relief  in  the  majority  of  these  cases,  and  are  nearly 
always  followed  by  a  temporary  diminution  of  the  diuresis. 
With  regard  to  the  treatment  of  Polyuria,  the  main  in- 
dications are  rest  and  an  endeavour  to  promote  nutrition 
generally.  To  attain  this  end  opium  or  codeia  should  be 
given  in  full  doses,  when  the  patient  first  comes  under  ob- 
servation. As  soon,  however,  as  the  nervous  system  is 
quieted,  and  the  rheumatic  and  neuralgic  pains  are  less 
severe,  it  should  be  discontinued,  lest  it  interfere  with 
digestion.  General  tonics,  such  as  iron,  phosphorus, 
quinine,  nux  vomica,  hydrochloric  acid,  and  cod-liver  oil, 
should  be  persevered  Avith.  When  there  is  a  history  of 
syphilis,  iodide  of  potassium  should  be  combined  with  these 
remedies.  Vapour  baths,  followed  by  tepid  douches,  sea- 
water  or  sea- salt,  give  great  relief  to  the  neuralgic  pains, 
and  also  soothe  the  nervous  system.  The  soluble  phos- 
phates may  be  administered ;    but  their  utility  in  these 


DIABETES    MELLITUS. 


409 


cases  is  questionable.  There  ai^pears  to  be  no  lack  of 
these  constituents  in  the  system ;  the  difficulty  seems 
rather  to  lie  in  the  want  of  power  of  the  tissues  to  retain 
them.  The  food  should  be  light  and  nutritious,  and  if 
iirea  be  greatly  in  excess,  the  nitrogenous  articles  of  diet 
should  be  reduced  to  a  minimum.  Alcohol  should  be 
avoided  ;  it  invariably,  even  in  small  quantities,  increases 
the  diuresis.  The  same  may  be  said  of  coffee.  Change  to 
dry  bracing  air  should  be  obtained  if  possible.  The  resi- 
dence should  face  South  or  South-west,  with  a  dry  sub- 
soil. The  patient  should  clothe  warmly,  keep  early  hours, 
and  avoid  all  excitement  and  fatigue. 


Diabetes  Mellitus  and  Glycosueia. 

153.  Varieties. — Sugar  occurs  pathologically  in  urine 
under  a  variety  of  conditions.  There  are,  however,  two 
forms  in  which  it  presents  itself,  viz.,  a  form  in  which  the 
discharge  of  sugar  is  persistent,  or  is  only  held  in  check 
by  the  adoption  of  a  strict  dietary ;  the  other,  which  is  of 
a  temporary  character.  The  first  is  usually  spoken  of  as 
diabetes  mellitus  or  true  diabetes,  signifying  the  drain  of 
sugar  taking  place  from  the  body ;  whilst  the  more  tran- 
sitory form  is  generally  designated  as  glycosuria,  in- 
dicating that  the  chief  clinical  significance  lies  in  the 
appearance  of  the  sugar  in  the  urine.  Although  the 
adoption  of  the  terms  diabetes  mellitus  and  glycosuria  to 
distinguish  between  the  persistent  and  temporary  forms  of 
the  disease  respectively,  may  be  considered  fanciful  and 
somewhat  arbitrary,  still  some  such  classification  is  neces- 
sary, if  we  wish  to  avoid  contusion,  and  rigidly  distinguish 
between  saccharine  urine,  the  result  of  profound  and  per- 
manent disorder  of  the  vaso-motor  centre,  that  regulates 


410  DISEASES    OF    THE    KIDNEY. 

the  glycogenic  function,  and  a  mere  fleeting  disturbance 
of  the  same.  Further,  "  diabetes  mellitus "  may  be 
divided  conveniently  into  two  forms.  One  severe,  cha- 
racterized by  an  excessive  discharge  of  sugar,  in  which 
although  the  amount  of  sugar  is  materially  reduced  by  a 
strict  avoidance  of  saccharine  and  amylaceous  articles  of 
diet,  yet  it  does  not  actually  disappear  ;  and  a  mild  form, 
in  which  on  the  assumption  of  a  rigorous  diet  the  sugar 
disappears  entirely  from  the  urine,  to  return  again,  how- 
ever, when  a  mixed  diet  is  resumed.  No  very  rigid  line 
can,  however,  be  drawn  between  the  two  classes,  the 
severe  form  may  gradually  become  milder,  whilst  the 
mild  form  may  suddenly  increase  in  severity.  So  also  in 
*'  glycosuria  "  the  derangement  of  the  glycogenic  function, 
may  be  so  great  as  to  cause  the  appearance  of  large 
amounts  of  siigar  in  the  urine,  so  that  in  many  respects 
the  case  resembles  the  confirmed  form  of  diabetes  melli- 
tus ;  whilst  on  the  other  hand  the  sugar  may  be  present 
in  only  small  quantities,  and,  what  is  so  especially  charac- 
teristic of  glycosuria,  in  amounts  that  fluctuate  consider- 
ably from  day  to  day. 

154.  Etiology. — One  of  the  most  important  predis- 
posing causes  of  non-traumatic  diabetes  is  undoubtedly 
that  of  hereditary  influence.  In  a  considerable  number  of 
cases  that  have  come  under  my  observation,  particularly 
among  private  patients,  in  which  the  disease  has  been  at- 
tributed to  some  other  cause,  a  close  examination  of  the 
family  history  has  revealed  a  morbid  taint,  predisposing 
to  this  affection  by  rendering  the  possessors  more  liable  to 
the  influence  of  exciting  causes.  In  most  the  transmis- 
sion is  direct,  passing  from  parent  to  child,  in  some  cases 
even  to  the  third  or  fourth  generation.  Thus,  in  one 
instance,  the  disease  was  brought  into  the  family  by  the 
great  grandmother  ;  of  her  children,  who  were  numerous, 


DIABETES    MELLITUS.  411 

and  lived  to  marry,  only  one  liad  children,  and  tliis  one 
was  known  to  have  had  diabetes.  Of  his  children,  two 
died  of  diabetes,  one  suffered  from  rheumatoid  arthritis  ; 
whilst  another  who  was  killed  early  in  life,  left  a  son 
who  is  diabetic,  and  at  the  age  of  forty  is  the  sole  sur- 
vivor of  what  promised  at  the  beginning  of  the  century 
to  be  a  numerous  family.  In  some  instances  the  trans- 
mission affects  one  line  of  descent.  A  diabetic  patient 
informs  me,  that  two  of  his  brothers  died  of  diabetes, 
and  a  third  has  the  disease  in  a  mild  form,  whilst  his 
sisters  have  escaped.  In  this  case  the  disease  came  into 
the  family  through  the  mother.  In  other  cases  the  here- 
ditary influence  is  not  direct,  the  parents  or  grand-parents 
never  having  suffered  from  the  disease,  but  from  what  may 
be  considered  allied  diathetic  conditions  ;  of  these,  gout 
and  rheumatoid  arthritis  seem  to  have  most  influence.  But 
whilst  hereditary  tendency  either  direct  or  indirect  can  be 
traced  in  most  cases  of  confirmed  diabetes,  still  there  are 
many  in  which  no  such  relationship  can  be  proved.  This 
is  no  doubt  owing  to  the  little  attention  hitherto  paid  to 
the  important  bearing  of  hereditary  influence  upon  disease. 
Besides,  we  must  not  overlook  the  fact  that  many  cases 
of  acute  diabetic  coma  would,  had  they  occurred  twenty 
or  even  ten  years  ago,  have  been  put  down  as  either  due 
to  heart  disease  or  serous  apoplexy,  and  in  this  way  the 
records  have  become  confused.  Mental  disturbances. — 
"  Sadness  and  long  sorrow"  since  the  time  of  Willis  (1645) 
has  been  recognized  as  one  of  the  causes  of  diabetes,  to 
which  may  be  added  strong  mental  emotion  of  all  kinds, 
such  as  business  anxieties,  protracted  intellectual  toil, 
shock,  fear,  etc.  I  have  been  struck  with  the  considerable 
number  of  diabetic  patients  I  see  in  the  out-patient  de- 
partment of  the  London  Hospital  who  attribute  the  disease 
to  vicissitude  and  want.      Cold. — Exposure  to  cold  and 


412  DISEASES    OF    THE    KIDNEY. 

tlrinking  cold  fluids  whilst  lieated  have  been  said  to  cause 
diabetes.  The  evidence  on  this  point  is  negative.  Sup- 
posing, however,  the  predisposition  exists,  there  can  be 
little  doubt  that  cold  may  act  as  an  exciting  cause.  Two 
sailors  both  referred  then-  illness  to  cold  and  exposure, 
and  a  gentleman  told  me  that  he  became  diabetic  after 
riding  home,  one  December  night,  on  the  outside  of  an 
omnibus.  On  arriving  home  he  had  several  rigors  and  was 
roused  several  times  to  pass  water.  Alarmed  at  the 
diuresis  he  consulted  his  medical  man,  who  found  he  was 
diabetic.  In  the  case  of  a  lad  aged  15,  the  only  cause  the 
parents  could  assign,  was  his  having  drunk  cold  water 
when  heated  ;  in  this  case,  however,  I  have  suspicions, 
that  some  latent  tubercular  disease  of  the  brain  existed. 
Constitutional  disorders. — Gout  and  rheumatoid  arthritis 
have  been  akeady  mentioned  as  allied  diathetic  conditions 
predisposing  to  diabetes.  The  relationship  to  gout  has 
long  been  recognized  by  the  profession  and  needs  no  fur- 
ther comment ;  but  the  connection  between  rheumatoid 
arthritis  and  diabetes  is  not  so  well  established.  Dr. 
Garrod  (op.  cit.)  was  the  first,  I  believe,  to  draw  attention 
to  this  point,  and  I  have  met  with  four  instances  in  which 
the  relationship  was  well  marked.  Diabetes  is  said  to 
supervene  upon  attacks  of  malaria,  and  that  residents  in 
a  malarious  district  are  very  liable  to  the  disease.  Dur- 
ing the  seven  years  I  was  connected  with  the  Dreadnought 
Sea^men's  Hospital,  where  a  very  considerable  number  of 
patients  suffering  from  malarial  affections  are  admitted 
every  year,  I  failed  to  find  a  single  case  in  which  the 
disease  was  attributable  to  that  cause.  Indeed,  among 
sailors,  diabetes  seems  very  rare,  for  during  the  seven 
years  I  acted  as  physician  to  that  institution  only  three 
cases  of  saccharine  diabetes  came  under  my  observation, 
two  of  these,  as  already  stated,  referred  the  disease  to 


DIABETES    MELLITUS.  413 

exposure  to  cold,  neither  had  ever  had  ague  ;  in  the  other, 
the  disease  followed  after  a  blow  on  the  skull.  However, 
although  I  never  noticed  a  decided  case  of  diabetes  associ- 
ated with  ague,  still  sugar  was  by  no  means  infrequently 
found  on  testing  the  urines,  sometimes  in  considerable 
amount,  but  which  generally  passed  off  when  arsenic  or 
quinine  was  given.  This  glycosuria  is  what  one  would 
naturally  expect,  since  malaria,  by  inducing  a  catarrhal 
condition  of  the  digestive  organs,  intefreres  materially 
with  saccharine  assimilation.  A  fact  pointed  out  many 
years  ago  by  Prout.  Malarial  glycosuria  assumes  import- 
ance with  regard  to  the  question  of  surgical  operations  ; 
Professor  VerneuH  {L' Union  Medicale,  No.  142)  having 
shown  very  conclusively  that  during  its  continuance 
wounds  do  not  close.  Diabetes  sometimes  supervenes 
on  the  subsidence  of  acute  affections,  such  as  pneumonia, 
acute  rheumatism,  typhoid  fever,  scarlet  fever,  etc. ;  in 
cases  of  this  kind  that  have  come  under  my  observation, 
I  have  found  on  enquiry,  either  a  family  predisposition  to 
the  disease,  or  else  reason  to  suspect  that  the  disease  had 
previously  existed  in  a  mild  form.  Dr.  Dickinson  (ojj.  cit., 
p.  62)  has  drawn  attention  to  the  frequency  of  glycosuria 
in  insanity.  Dr.  Hales  White  {Path.  Soc.  Trans.,  1883) 
has,  however,  questioned  the  accuracy  of  this  assertion. 
Food. — Excess  of  starchy  and  saccharine  food  undoubtedly 
induces  glycosuria  in  some  persons  till  the  effect  of  the 
meal  passes  off,  but  whether  habitual  excess  will  even- 
tually cause  true  diabetes  is  very  doubtful.  During  the 
"  lentil "  craze,  some  five  years  ago,  I  saw  two  patients 
who  had  reduced  the  amount  of  animal  food  to  a  mini- 
mum, taking  hominy  for  breakfast,  lentil  soup  for  lunch 
and  dinner,  with  rice  and  other  farinaceous  puddings, 
both  became  glycosuric,  but  on  resumiug  an  ordinary 
mixed  diet  they  speedily  recovered.     These  were  probably 


414  DISEASES    OF    THE    KIDNEY. 

instances  of  individuals  extremely  susceptible  to  the  in- 
fluence of  sugar,  and  probably  the  tendency  was  aggra- 
vated by  the  sudden  change  in  their  mode  of  Hving.  Con- 
firmed vegetarians,  or  West  Indian  negroes,  who  largely 
consume  the  sugar  cane,  however,  do  not  appear  to  be 
particularly  liable  to  diabetes.  Excessive  indulgence  in 
alcohol  has,  by  some  writers,  been  said  to  cause  diabetes. 
Dr.  Dickinson  (Med.  Chir.  Trans.,  vol.  Ivi.)  with  his  iisual 
industry  has  exposed  the  fallacy  of  this  statement.  There 
is,  however,  probably  some  truth  in  the  statement  that 
the  immoderate  use  of  acid  wines  and  cider  have  some- 
times occasioned  the  disease.  Injuries  to  the  head  or  blows 
and  falls  likely  to  affect  the  brain  by  indirect  violence, 
are  not  infrequently  followed  bythe  appearance  of  sugar 
in  the  urine,  which  in  some  rare  cases  has  become  per- 
sistent. Blows  over  the  abdominal  region  have  been  said 
to  have  sometimes  had  the  same  effect,  but  in  these  cases 
it.  is  difficult  to  exclude  the  possibility  of  some  remote  in- 
jury to  the  head.  The  existence  of  intra- cranial  tumours, 
or  of  softening  in  the  neighbourhood  of  the  fourth  ventri- 
cle, may  cause  transitory  or  permanent  diabetes;  but  such 
instances  are  not  so  common  as  with  insipid  diabetes. 

General  Etiology. — Saccharine  diabetes  is  essentially 
a  disease  of  adult  hfe.  Dr.  Dawson  Williams  {Path.  Soc. 
Trans.,  1883)  has  compiled,  from  the  returns  of  the 
Eegistrar-General,  a  table  showing  the  age  at  which 
death  from  diabetes  most  commonly  occurs,  and  the  pro- 
portion of  males  to  females,  which  makes  this  very  plain. 
According  to  this  table,  the  proportion  of  male  cases  to 
female  is  as  3  to  1'7.  This,  however,  I  am  convinced  is 
too  high,  since  I  believe  in  females,  that  many  deaths 
from  diabetes  occur  in  connection  with  the  puerperal 
state,  without  the  disease  having  been  recognized.  In 
Dr.   Matthews   Duncan's   {Trans.    Ohst.    Soc,  vol.   xxiv.) 


DIABETES    MELLITUS. 


416 


interesting  collection  of  cases  of  puerperal  diabetes,  we 
see  in  how  many  instances  the  saccharine  condition  of  the 
urine  was  discovered  accidentally. 


Deaths  from  Diabetes  durmg  Decenuim,  1871-1880. 

Males. 

Females. 

Total. 

Total  Tinder  5  years    .     .     . 

23 

25 

48 

From  5  to  10  years 

65 

64 

119 

„     10  „  15    „ 

134 

133 

267 

„    15  „  20    „ 

284 

171 

455 

„     20  „  25    „ 

348 

201 

549 

„     25  „  35     „ 

816 

5U2 

1318 

„    35  „  45    „ 

906 

494 

1400 

,,    45  ,,  55    „ 

954 

547 

1501 

,,     55  „  65    ,, 

1236 

660 

1896 

„    65  „  75    „ 

922 

464 

13S6 

„     75  „  85    „ 

229 

121 

350 

„    85  „  95    „ 

12 

2 

14 

Tota 

s  .     . 

5929 

3374 

9303 

Dr.  Dawson  Williams  has  also  drawn  up  an  instructive 
table  showing  that  diabetes  is  becoming  year  by  year 
more  common,  and  also  that  urinary  diseases  are  increas- 
ing proportionately  more  than  nervous  diseases. 

Mean  Annual  Rate  of  Mortality  in  Engla7id.     Annual 
Deaths  to  1,000,000  Living. 


Average 

( 

1850 

1855 

i860 

1865 

1870 

1875 

1850 

Years   .     .    .     .  i 

to 

to 

to 

to 

to 

to 

to 

l 

1854- 

1859. 

1864. 

1869. 

1874. 

1879. 

1S79. 

Deaths  from  all  causes  . 

22,299 

22,052 

22,248 

22,760 

22,019 

21,250 

22,105 

Nervous 

Diseases  . 

2,777 

2,758 

2,823 

2,859 

2,817 

2,812 

2,808 

>)                59 

Urinary 

Diseases  . 

190-6 

227- 

270-6 

320-2 

352-2 

420- 

296-9 

5>                5) 

Diabetes     . 

23- 

24-8 

28-4 

32-2 

35-2 

40-6 

30-7 

" 

Gout      .     . 

12-4 

13-2 

13-4 

18-2 

20-8 

25-6 

17-3 

416  DISEASES    OF    THE    KIDNEY. 

Persons  of  sanguine  temperament  and  fair  hair  are 
said  to  be  more  prone  to  the  disease  than  the  melan- 
chohc  and  dark  haired,  but  I  imagine  the  distinction 
is  fanciful.  There  is  one  point,  however,  I  can  affirm, 
that  diabetics  are  generally  individuals  of  superior  in- 
telligence. Hufeland  observes  he  never  saw  a  stupid 
man  affected  with  diabetes.  Dr.  Dickinson,  from 
statistics  collected  with  amazing  industry,  has  arrived 
at  the  conclusion  that  diabetes  is  more  abundant  in 
agricultural  districts  than  in  manufacturing  and  min- 
ing, and  that  it  is  more  common  in  the  colder  than 
warmer  countries.  Dr.  Koberts,  however,  is  of  opinion 
that  the  disease  is  more  frequent  in  urban  than  in  rural 
districts,  and  this  I  think  is  in  accord  with  general  experi- 
ence, though  Dr.  Dickinson's  statistics  are  indeed  strongly 
against  such  a  supposition.  Can  the  fact,  that  diabetics 
improve  in  country  air — and  many  leave  the  towns  to 
reside  in  the  country  for  the  purpose  of  maintaining 
health — and  that  the  imported  factory  hand  or  miner  pro- 
bably goes  back  to  die  in  the  workhouse  of  the  rural  dis- 
trict from  which  he  was  drawn,  account  for  the  greater 
number  of  deaths  from  diabetes  that  undoubtedly  are  re- 
corded in  rural  districts  ?  Dr.  Dickinson's  theory,  that 
cold  and  exposure  are  the  causes  predisposing  to  this 
excess  of  mortahty  from  diabetes,  can  hardly  be  accepted, 
since  if  this  were  so,  then  the  disease  ought  to  be  common 
among  the  sailors  of  our  mercantile  marine  ;  whereas,  as 
the  experience  of  the  Seamen's  Hospital  shows  it  is  far 
from  being  frequently  met  with.  Dr.  Dickinson's  statis- 
tics also  show  that  the  disease  is  more  prevalent  in  the 
colder  and  bleaker  Eastern  counties  than  in  the  "Western. 
Yet  here,  again,  we  are  confronted  with  the  fact,  that  the 
disease  is  tolerably  frequent  in  inter-tropical  countries,  as 
Ceylon  for  instance,  whilst  it  is  comparatively  rare  in 
Eussia. 


DIABETES    MELLITUS.  417 

So  far  we  have  considered  the  causes  that  may  give  rise 
either  to  permanent  or  temporary  forms  of  the  disease,  we 
must  now  briefly  refer  more  especially  to  those  that  con- 
cern the  latter  form.  This  is  chiefly  induced  by  the 
passing  action  of  certain  toxic  agents,  either  introduced 
from  without,  or  from  some  altered  condition  of  the  blood 
itself.  Glycosuria  has  been  found,  experimentally,  to  follow 
the  administration  of  carbonic  oxide,  chloroform,  alcohol, 
ether,  when  given  in  large  doses ;  strychnine  and  morphia 
have  the  same  effect.  The  ingestion  of  large  quantities  of 
acid  is  sometimes  followed  by  glycosuria,  according  to 
Pavy,  phosphoric  acid  has  a  special  irritating  effect  upon 
the  liver ;  an  increase  or  an  accumulation  of  uric  acid  in 
the  blood  has  also  been  regarded  as  a  cause  of  "  gouty 
glycosuria."  It  has  also  been  shown,  when  the  red  blood 
corpuscles  are  extensively  destroyed,  that  sugar  appears 
in  the  urine.  To  these  morbid  conditions  of  the  blood 
may  be  added  those  of  rheumatism,  malaria,  and  cho- 
lera, lactation,  etc.  Abnormal  conditions  of  the  alimen- 
tary tract  leading  to  malassimilation  of  the  amylaceous 
and  saccharine  elements  of  the  food,  play,  although 
their  nature  is  not  yet  determined,  an  important  part 
in  the  production  of  glycosuria.  The  frequent  associa- 
tion of  organic  disease  of  the  pancreas  with  permanent 
diabetes,  makes  it  not  improbable  that  a  temporary 
functional  derangement  of  this  organ,  by  causing  an 
arrest  of  the  highly  alkaline  secretion,  may,  by  lowering 
the  alkalescence  of  the  blood  in  the  portal  vessels,  disturb 
the  hepatic  circulation,  and  thus  induce  glycosuria. 
Sugar  not  infrequently  makes  its  appearance  during  states 
of  debility,  thus  the  urine  may  become  saccharine  during 
convalescence  from  influenza,  or  after  blood-poisoning  from 
sewer  gas,  etc.  Overwork,  care,  anxiety,  or  even  simple 
debility,  will  frequently  be  attended  with  saccharine  urine. 

EE 


418  DISEASES   OF    THE    KIDNEY. 

I  liave  noticed  that  women  at  "the  change"  often 
pass  considerable  quantities  of  nrine  containing  sugar. 
The  glycosuria,  or  rather  the  mild  form  of  diabetes,  that 
elderly  persons  so  frequently  exhibit,  is  the  result  of  ex- 
haustion and  debility.  Claude  Bernard  looked  upon  the 
appearance  of  sugar  in  these  cases  as  a  salutary  effort  of 
nature  to  repair,  by  an  over-production  of  glycogen,  the 
exhaustion  of  the  organism ;  but  it  is  more  probable  that 
it  is  due  to  a  general  nervous  exhaustion  bringing  about 
vaso-motor  paralysis. 

155.  Symptoms. — "When  the  amount  of  sugar  passing 
out  of  the  body  is  considerable,  it  is  usually  attended  with 
marked  symptoms.  These  are,  great  bodily  weakness, 
thirst,  excessive  micturition  and  saccharine  urine.  Some 
cases,  although  there  may  a  considerable  amount  of  sugar 
in  the  urine,  complahi  neither  of  weakness,  thirst,  or  ex- 
cessive micturition ;  these,  however,  are  exceptional  in- 
stances, and  generally  occur  in  glycosuric  and  not  truly 
diabetic  cases.  The  symptoms  usually  come  on  insidi- 
ously, and  the  disease  gradually  developes ;  in  some 
instances  the  invasion  is  sudden,  the  patient  being  able  to 
refer  to  the  very  day  on  which  the  disease  began.  These 
cases  generally  run  an  acute  course.  The  symptoms 
vary  very  much  in  individual  cases,  being  more  pro- 
nounced in  some  cases  than  in  others.  Bodily  debility 
is  generally  the  first  symptom  complained  of,  and  on 
being  questioned,  the  patient  also  complains  of  thirst 
and  a  frequent  desne  to  pass  water.  Sometimes  if 
we  examine  the  trousers  or  stockings,  we  may  find 
whitish  sticky  stains  caused  by  drops  of  saccharine  urine 
falling  on  them.  The  loss  of  strength  is  also  generally 
attended  in  severe  cases  with  emaciation,  though  in  mild 
forms  of  the  disease ;  the  patient  though  complaining  of 
feehng  tired  and  weak,  maintains  his  usual  bulk.     The 


DIABETES   MELLITUS.  419 

temperature  is  subnormal,  unless  some  secondary  lung 
complication  exists,  it  has  been  recorded  as  low  as  93°  F. ; 
the  more  usual  range  is  95*5°  F.  to  97°  F.  The  thirst  is 
always  aggravated  by  the  ingestion  of  saccharine  and 
starchy  food ;  it  differs  from  that  of  diabetes  insipidus,  in 
that  the  desire  seems  to  be  rather  to  alleviate  the  sensa- 
tion of  thirst,  than  to  swallow  enormous  quantities  of 
water.  A  patient  with  hydruria  will  seize  a  water-jug  and 
empty  it  at  a  draught,  whilst  the  patient  with  mellituria 
prefers  oft  repeated  sips. 

The  UKINE  at  quite  an  early  period  acquires  a  peculiar 
character.  It  loses  its  amber  tint,  and  becomes  a  green- 
ish-yellow, and  if  exposed  to  the  air  for  a  few  days,  often 
becomes  deeply  red,  probably  from  oxidation  changes  of 
the  indican,  which  is  always  in  excess  in  diabetic  urines. 
Its  reaction  is  nearly  always  highly  acid,  and  the  acidity 
increases  by  exposure  to  air,  and  long  resists  alkaline 
fermentation.  The  quantity  of  urine  is  usually  very 
greatly  increased,  and  generally  bears  a  fairly  definite 
proportion  to  the  amount  of  sugar  excreted.  This  is  not 
always  the  case,  however,  and  I  have  met  with  two  in- 
stances in  which  with  a  very  considerable  excretion  of 
sugar  the  amount  of  urine  hardly  exceeded  the  normal. 
Both  cases  ran  an  acute  course,  and  died  of  diabetic  coma. 
The  amount  of  urine,  however,  passed  in  ordinary  cases  of 
diabetes,  ranges  from  4000  to  8000  c.c,  six  to  twelve  pints, 
though  exceptionally  it  has  been  known  to  reach  the 
prodigious  quantity  of  more  than  thirty  pints.  The  S2:)eciJiG 
gravity,  owing  to  the  increase  of  solid  matter  caused  by 
the  sugar,  is  always  raised,  and  in  cases  of  ordinary 
severity  ranges  from  1*028  to  l'04i).  It  may,  however, 
rise  considerably  higher,  and  a  degree  of  1"070  has  been 
recorded.  On  the  other  hand,  in  exceptional  instances  it 
may  fall  below  1*020;  these,  however,  are  usually  cases  of 

EE  2 


420  DISEASES    OF    THE    KIDNEY. 

glycosuria,  in  which  the  saccharine  state  of  the  urine  is 
purely  symptomatic  of  some  other  morbid  condition.  The 
specific  gravity  of  diabetic  urine  diminishes  when  it  is 
kept  some  time,  owing  to  the  transformation  of  the  sugar 
by  vinous  fermentation  and  the  disengagement  of  alcohol. 
The  elimination  of  Urea  is  always  increased,  and  this  in- 
crease is  usually  proportionate  to  the  severity  of  the 
disease.  Thus  in  mild  cases  in  which  the  amount  of 
sugar  excreted  is  readily  checked  by  the  adoption  of  a 
restricted  dietary,  the  increase  is  not  considerable ;  where- 
as, in  severe  instances  of  the  disease  the  increase  in  the 
proportion  of  the  urea  to  the  sugar  excreted,  is  often  as 
one  to  five,  or  even  one  to  three.  In  making  the  calcula- 
tion, the  normal  amount  of  urea  excretion  must  be  de- 
ducted. Thus  a  patient  who  in  the  twenty-four  hours 
excreted  69  grms.  of  urea,  and  148  grms.  of  sugar,  was 
calculated  from  his  normal  body  weight  to  have  a  normal 
excretion  of  36  grms.  of  urea,  consequently  the  morbid 
excess  of  urea  over  the  physiological  excretion,  amounted 
to  33  grms.,  or  as  1  to  4*5  in  proportion  to  the  amount 
of  sugar  discharged.  This  excess  of  urea,  however, 
must  not  be  considered  to  be  entirely  pathological, 
since  a  considerable  proportion  is  due  undoubtedly  to  the 
increased  ingestion  of  nitrogenous  food.  It  is,  however,  so 
difficult  to  discriminate  between  the  two,  that  it  is  more 
convenient  to  make  the  calculation  with  only  the  de- 
duction of  the  normal  excretion  of  urea,  without  at- 
tempting  to  subtract  that  caused  by  the  additional 
ingestion  of  nitrogenous  food.  It  has  been  stated  by 
some  writers  that  Uric  Acid  is  diminished  in  diabetes, 
I  have  never  observed  a  diminution,  but  always  a 
slight  excess  of  the  normal.  Owing,  however,  to  the 
abundant  aqueous  discharge  by  the  kidneys,  it  is  rarely 
deposited  in  a  crystalline  state,  a  fact  which  probably  ac- 


DIABETES    MELLITUS.  421 

counts  for  the  idea  that  it  was  actually  diminished  in 
quantity,  and  for  another  erroneous  statement,  that  sac- 
charine diabetes  alternates  with  manifestations  of  the 
"  uric  acid  diathesis."  The  truth  being  that  uric  acid,  if 
anything  is  increased  in  diabetes,  and  that  its  deposition 
from  the  urine  when  the  amount  of  sugar  excreted  is 
diminished,  or  entirely  checked,  by  diet,  really  means  that 
the  diuresis  being  less,  the  urine  is  more  concentrated, 
and  consequently  the  tendency  to  throw  down  uric  acid 
and  urates  is  increased ;  and  this  condition  is  no  doubt 
heightened  by  the  continuation  of  a  highly  animal  diet  for 
sometime  after  sugar  has  disappeared,  a  diet  which  keeps 
the  urine  above  its  normal  degree  of  acidity.  Hippuric 
Acid  is  often  found  in  excess  in  diabetic  urine.  Those 
writers  who  suppose  that  the  excretion  of  uric  acid  is 
decreased  in  diabetes,  hold  that  it  is  replaced  by  hippuric 
acid.  A  careful  examination  of  the  urine,  how^ever,  will 
prove  that  both  are  usually  increased.  The  amount  of 
Phosphoric  Acid  excreted  is  in  most  cases  above  the  nor- 
mal, this  is  perhaps  due  in  some  measure  to  diet,  but 
when  the  increase  is  very  great  not  wholly  so,  since  the 
phosphates  of  an  increased  meat  allowance  hardly  coun- 
ter-balance the  phosphates  of  the  bread  withdrawn. 
Some  portion  of  the  excess  is  also  caused  by  the  drain  of 
water  going  on  through  the  body,  washing  out  the  tissues, 
but  the  main  increase  is  undoubtedly  due  to  increased 
metabolism  going  on  in  the  nervous  system.  It  has  also 
been  shown  that  in  addition  to  the  increased  elimination 
of  phosphorus,  as  phosphoric  acid,  a  considerable  amount 
of  unoxidized  phosphorus  is  passed  into  the  urine  in  dia- 
betes (see  p.  98).  Chlorine  and  Sidphuric  Acid  are  gene- 
rally found  increased  but  not  to  such  amounts  as  cannot  be 
accounted  for  by  the  highly  animalized  diet  adopted. 
According  to  Dr.  Dickinson,  lime  salts  are  in  some  cases 


422  DISEASES   OF    THE    KIDNEY. 

of  diabetes  eliminated  in  excess.  Dr.  Dickinson  accounts 
for  this  by  assuming  that  phosphoric  acid  being  in  excess 
in  the  blood  withdraws  lime  from  the  tissues  ;  but  this  is 
not  XDrobable,  since  the  phosphoric  acid,  as  separated, 
would  be  ah'eady  combined  with  some  base  ;  it  is  more 
likely  for  oxaHc  acid,  formed  by  the  oxidation  of  some  of 
the  sugar  in  the  tissues  or  blood,  to  act  in  this  way,  form- 
ing oxalate  of  lime,  of  which  a  considerable  quantity  is 
usually  met  with  in  diabetic  urine.  Or  lime  may  be  with- 
drawn owing  to  the  peculiar  physico-chemical  affinity 
that  seems  to  exist  between  it  and  sugar.  Glucose  is  of 
course  the  most  important  constituent  of  diabetic  urine. 
The  amount  may  vary  from  a  mere  trace,  to,  in  exceptional 
cases,  several  pounds  per  diem.  The  average  range,  how- 
ever, of  most  diabetic  cases  is  from  about  three  ounces  to 
ilb,  in  the  twenty -four  hours.  But  cutting  off  all  saccha- 
rine and  starchy  food,  the  quantity  of  sugar  in  the  urine 
is  diminished,  and  in  some  cases  it  entirely  disappears.  If 
the  amount  of  sugar  be  frequently  estimated,  it  ;wi]l  be 
found  to  fluctuate  considerably  from  day  to  day.  It  is 
often  difficult  to  account  for  these  diurnal  variations,  ex- 
cept on  the  supposition  that  the  patient  has  surreptitiously 
transgressed.  But  in  spite  of  the  closest  supervision,  such 
variations  do  occur  that  recourse  must  be  had  to  some 
other  supposition.  A  medical  friend  who  is  diabetic,  and 
who  carefully  watches  the  turns  of  his  disease,  tells  me 
these  variations  depend  very  much  on  the  state  of  his 
bodily  health.  Whenever,  he  says,  his  liver  gets  out  of 
order,  and  he  has  a  bilious  attack,  or  if  he  sits  up  late 
writing,  or  is  in  any  way  worried,  the  sugar  increases 
without  being  referred  to  any  relaxation  of  his  dietetic  jDre- 
cautions.  The  amount  of  sugar  -is  always  decreased  by 
fasting,  and  increased  after  food ;  the  period  when  the 
greatest  amount  of  sugar  passes  out  of  the  body,  being 


DIABETES    MELLITUS.  423 

about  three  hours  after  a  meal.  "When  the  case  is  about 
to  terminate  fatally,  there  is  generally  a  considerable 
diminution  in  the  amount  of  sugar  excreted,  though  that 
it  completely  disappears  is  doubtful,  since  there  is  usually 
no  dif&culty  in  determining  the  presence  of  sugar  in  urine 
taken  from  the  bladder  after  death.  Pyrexial  compHca- 
tions  also  temporarily  diminish  the  amount  of  sugar  ex- 
creted. 

Many  substances  besides  those  above  enumerated,  may 
be  casually  present  in  diabetic  urine.  Albumin. — Traces 
of  albumin  are  usually  met  with  in  the  urine  of  cases  of 
confirmed  diabetes,  it  is  probably  caused  by  the  irritation 
produced  by  the  constant  passage  of  saccharine  urine 
through  the  urinary  tubules.  No  renal  changes,  beyond 
increase  of,  and  fatty  changes  in,  the  epithelium,  have 
been  noticed.  Besides  this,  diabetes  has  no  connection 
with  albuminuria  or  renal  disease  of  any  kind.  There 
are,  however,  certain  cases  of  albuminuria  in  wliich  the 
urine  is  intermittingly  saccharine,  but  these  are  not  cases 
of  diabetes  but  only  of  transient  glycosuria.  They  occur 
generally  in  persons  whose  health  has  been  broken  by 
liabits  of  dissipation,  and  who  are  victims  of  chronic  alco- 
holism, syphilitic  cachexia,  etc.  The  urine  is  usually  of 
low  specific  gravity  (1-010-1-015),  and  the  amount  of  sugar 
present  is  never  very  great,  rarely  exceeding  three  per  cent. 
Acetone. — Saccharine  urine  usually  contains  acetone,  or  a 
body  that  yields  acetone  when  the  urine  is  distilled  with 
hydrochloric  acid.  Acetone  is  a  limpid,  colourless  Hquid, 
specific  gravity  0-7921,  having  a  peculiar  etherial  odour. 
Its  solution  gives  a  mahogany-red  coloration  with  ferric 
chloride.  Heated  with  iodide  of  potassium  and  caus- 
tic potash,  iodoform  ,is  formed.  A  solution  of  nitro- 
prusside  of  sodium  and  ammonia  added  to  a  fluid  con- 
taining  acetone,   and  the   mixture    well    shaken,    gives 


424  DISEASES    OF    THE    KIDNEY. 

rise  to  rose-violet  colour.  As  already  stated  (p.  32)  the 
antecedent  of  acetone  ia  tlie  blood  is  aceto- acetic  acid.  It 
has  been  objected  by  Le  Nobel,  however,  that  aceto- acetic 
acid  is  so  volatile,  that  it  cannot  be  kept  even  a  few  hours 
in  a  stoppered  bottle,  and  yet  the  substance  that  gives  rise 
to  acetone  can  be  extracted  from  the  urine  with  ether.  It 
is  probable,  however,  that  aceto- acetic  acid  does  not  exist 
in  a  free  state,  but  in  combination  with  some  base, 
or  is  derived  from  a  more  stable  compound.  Thus 
Minkowski  has  recently  discovered  the  presence  of  an 
acid  (/3-  or  pseudo-oxybutyric  acid)  in  diabetic  urine, 
which  is  capable  of.  breaking  up  into  aceto- acetic  acid. 
Acetone,  or  acetone  yielding  bodies,  however,  is  not  alone 
found  in  diabetic  urines,  since  it  has  been  met  with  in  the 
urines  of  many  acute  diseases,  scarlet  fever,  pneumonia 
and  the  like,  also  in  anemia,  dyspepsia,  cancer  of  the 
stomach,  etc. 

Inosite  may  be  present  in  diabetic  uriue,  and  is  of  no 
special  significance ;  not  infrequently  it  appears  unaccom- 
panied by  glucose,  giving  rise  to  a  condition  known  as  iaosi- 
turia  (see  also  p.  126).  Lcevuloseis  also  sometimes  present 
in  diabetic  urine,  it  can  be  distinguished  from  glucose  by 
its  left-handed  polarisation  (p.  128).  When  glucose  or 
Ifevulose  are  both  present  in  sufficient  quantities,  as  is 
sometimes  the  case,  the  evidence  drawn  from  the  polari- 
scope  will  be  negative,  the  left-handed  rotation  of  one 
sugar,  interfering  with  the  right-handed  rotation  of  the 
other. 

In  addition  to  such  special  symptoms,  as  emaciation, 
thirst,  diuresis  and  saccharine  urine,  there  are  others  of 
more  general  character  which  may  be  present  in  some 
cases  and  absent  in  others.  Anomalous  nervous  symp- 
toms are  frequent,  such  as  cramps  in  the  legs,  and  the 
pecuhar  neuralgic  pains,  coming  on  especially  after  food, 


DIABETES    MELLITUS.  425 

which  chiefly  attack  the  epigastric,  himbar,  sciatic  and 
brachial  nerves  (see  also  p.  33).  Cutaneous  hyperassthesia, 
usually  localized.  Sudden  sweats,  frequently  unilateral, 
or  affecting  only  the  palms  of  the  hands  or  the  soles  of 
the  feet.  Also  sensations  of  great  internal  bodily  heat. 
Failure  of  vision,  due  to  premature  presbyopia,  glycosuric 
amaurosis,  cataract,  or  to  actual  changes  in  the  fundus 
oculi  (see  p.  37),  often  occur.  The  intellectual  faculties 
are  not  affected  in  diabetes,  and  many  distinguished  men, 
who  have  suffered  from  the  disease,  have  performed  their 
professional  duties,  provided  they  did  not  entail  much 
bodily  exertion,  with  clearness  and  vigour  up  to  the  very 
last.  They,  however,  as  a  rule  suffer  much  from  nervous 
irritability,  hypochondriasis,  and  are  disinclined  for  social 
pursuits.  The  sexual  instinct  is  lost  at  a  very  early  period 
of  the  disease,  though  an  amelioration  of  the  symptoms  is 
generally  marked  by  its  return.  The  breath  has  a  peculiar 
odour,  like  that  of  decaying  apples,  and  the  mouth  is  dry, 
with  usually  a  sweetish- acid  taste,  and  the  tongue  covered 
with  a  tliick  sticky  saliva,  which  forms  streaks  over  the 
organ  which  is  often  bright-red.  The  gums  are  usually 
tender  and  spongy,  and  have  a  tendency  to  recede,  leaving 
the  roots  of  the  teeth  bare  and  loosened.  The  appetite 
may  continue  ravenous  till  the  end,  but  usually  in  the 
later  stage  declines,  and  there  may  then  be  a  disgust  for 
food  though  the  craving,  sinking  sensation  remains.  Dia- 
betic patients  suffer  much  from  flatulence,  causing  painful 
distension  of  the  abdomen,  eructations  and  sometimes 
retching.  The  bowels  are  constipated,  the  motions  when 
passed  being  dry  and  scybalous,  this  state  sometimes  gives 
place  to  a  troublesome  diarrhoea,  especially  in  a  late  stage 
of  the  disease.  The  skin  is  usually  harsh,  dry,  and,  owing 
to  the  disappearance  of  the  subcutaneous  fat,  wrinkled, 
the  surface  is  generally  pallid  or  of  unhealthy  yellowish 


426  DISEASES    OF    THE    KIDNEY. 

tinge,  but  the  cutaneous  vessels  of  the  face  are  often  in- 
jected, giving  a  deep  reddish  tinge  to  the  checks,  so  that 
the  patient's  face  looks  like  a  withered  winter  apple.  This 
dry  state  of  the  skin  is  often  succeeded  by  sweats  of  longer 
or  shorter  duration,  sometimes  these  sweats  are  unilateral, 
sometimes  they  only  affect  the  extremities.  In  an  ad- 
vanced stage  of  the  disease,  boils,  small  carbuncles,  and 
impetiginous  eruptions  often  occur,  whilst  the  contact  of 
the  saccharine  urine  produces  a  troublesome  eczema  of  the 
vulva  in  females,  and  of  the  prepuce  and  glans  penis  in  men. 
Patches  of  eczema,  lichen,  or  psoriasis,  in  different  parts  of 
the  body,  may  appear  during  the  course  of  the  disease. 
Spontaneous  gangrene  sometimes  occurs  in  protracted 
cases  of  the  disease,  it  may  invade  the  chin,  the  nose,  the 
lungs,  or  other  parts  of  the  body,  but  most  frequently  at- 
tacks the  feet.  (Edema  of  the  lower  extremities  occasion- 
ally sets  in  towards  the  close  of  the  disease,  and  is 
apparently  due  to  the  existing  anaemia.  Such  are  the 
main  features  exhibited  by  cases  of  typical  diabetes,  though 
the  disease  may  exist  in  a  mild  form  for  many  years  with- 
out causing  the  patient  much  discomfort,  indeed  without 
in  any  way  affecting  his  general  health,  or  interfering  with 
the  nutrition  of  the  body. 

The  question  of  diabetic  coma  is  best  reserved  till  we 
consider  the  course  and  pathology  of  the  disease. 

156.  Diagnosis. — A  typical  case  of  diabetes  cannot  be 
taken  for  anything  else,  and  our  difficulty  is  to  determine 
between  true  diabetes  and  mere  glycosuria.  In  the 
majority  of  cases,  when  the  patient  first  comes  under  ob- 
servation, it  is  impossible  at  once,  to  come  to  a  definite 
conclusion,  though  we  may  be  helped  by  the  following 
considerations.  Glycosuria,  as  a  rule,  is  not  always 
attended  with  the  ordinary  symptoms  of  diabetes,  and 
the  saccharine  condition  of  the  urine  is  only  detected 


DIABETES    MELLITUS.  427 

by  chance,  owing  to  a  routine  examination  of  tlie 
urine.  It  also  usually  runs  an  anomalous  course,  and 
there  are  greater  fluctuations  in  the  amount  of  sugar,  than 
is  noticeable  in  confirmed  diabetics ;  moreover,  the  amount 
of  sugar  excreted  hardly  ever  reaches  so  high  a  grade. 
Cases  of  glycosuria,  however,  may  occur,  which  in  then* 
onset  resemble  true  diabetes,  both  with  regard  to  the 
amount  of  sugar  excreted,  the  profuse  diuresis  and  other 
symptoms  ;  these  acute  cases  usually  speedily  recover, 
and  are  often  quoted  as  recoveries  from  diabetes.  A  good 
case  of  this  kind  is  related  by  Dr.  Weber,  and  quoted  by 
Dickinson,  of  a  merchant  who  during  the  commercial 
crisis  of  1857  became  glycosuric,  passing  about  eight  pints 
of  urine,  specific  gravity  I'DSQ-VOid:,  who  recovered  in  three 
weeks,  remained  free  from  all  symptoms  till  1866  when 
during  another  crisis,  again  became  glycosuric  and  again 
recovered.  Glycosuria  is  also  generally  attended  with 
some  other  morbid  condition,  such  as  functional  derange- 
ment of  the  liver,  the  result  of  plethora;  gouty  proclivities ; 
or  conditions  of  debility,  such  as  follow  on  diphtheria, 
blood-poisoning,  x^rolonged  lactation  and  the  like  ;  or  after 
severe  bodily  and  mental  exhaustion,  or  the  weakness  of 
old  age.  It  is  rare  for  glycosuria  to  be  long  persistent, 
and  it  generally  yields  to  treatment,  and  though  like  dia- 
betes the  sugar  in  the  urine  is  diminished  when  starchy 
and  saccharine  food  is  cut  off,  still  the  influence  of  diet  is 
not  usually  so  marked^  as  it  is  in  the  case  of  diabetes. 
That  is  to  say,  we  frequently  meet  with  cases  of  glycosuria 
in  which  the  sugar  is  scarcely  controlled  in  spite  of  dietetic 
restrictions,  whilst  those,  in  which  it  is  not  increased  by 
permitting  a  mixed  diet,  recover  when  the  cause  which 
brought  about  the  increased  glycogenetic  activity  of  the 
hepatic  cells  has  passed  away.  The  great  distinction, 
however,  between  glycosuria  and  diabetes  hes  in  the  fact 


428  DISEASES    OF    THE    KIDNEY. 

that  the  former  is  curable,  whereas  Ihe  latter  relapses 
whenever  the  dietetic  restrictions  are  relaxed.  It  is  also 
important  for  us  to  bear  in  mind,  in  expressing  an  opinion 
with  regard  to  any  given  case,  that  a  transient  or  inter- 
mitting glycosuria  may  at  any  time  pass  into  confirmed 
diabetes.  Sugar  may  be  added  to  the  urine  for  the  pur- 
pose of  deception,  impostors,  however,  not  being  educated 
in  pathological  chemistry  usually  employ  cane  sugar,  so 
the  fraud  is  easy  of  detection. 

157.  Course. — As  a  rule  saccharine  diabetes  runs  a 
chronic  course,  but  the  progress  varies  greatly  in  indivi- 
dual cases.  In  some  the  disease  commences  insidiously, 
and  progi-esses  slowly  and  mildly  for  years,  and  then  sud- 
denly becomes  aggravated  and  speedily  carries  off  the 
patient.  In  others  the  disease  at  first  assumes  a  severe 
type,  and  then  under  treatment  becomes  milder  and  so 
remains  stationary  for  a  considerable  period,  neither  ad- 
vancing nor  declining.  Again  there  are  cases,  as  Dr.  Pavy 
[op.  cit.)  has  pointed  out,  that  progress  as  it  were  by  a 
series  of  short  bounds  or  leaps,  very  much  hke  cases  of 
progressive  muscular  atrophy  or  locomotor  ataxy.  Thus, 
when  they  first  come  under  observation  the  disease  is 
checked  by  diet,  then  there  is  another  exacerbation  which 
is  again  checked,  but  this  time  opium  is  requu-ed  in  addi- 
tion to  dietetic  restrictions,  and  which  has  to  be  repeatedly 
increased  as  each  fresh  downward  step  is  taken,  till  finally 
a  stage  is  reached  in  which  neither  diet  nor  opium  avails 
to  control  the  advance  of  the  disease.  Lastly,  there  are 
cases  of  a  "foudroyant"  type  in  which  the  disease  sets 
in  suddenly  with  great  severity,  and  rapidly  proves  fatal 
through  diabetic  coma.  These  cases,  however,  are  quite 
exceptional,  and  most  that  have  been  recorded,  probably 
belong  to  the  first  class  of  cases  mentioned,  viz.,  a  mild 
form  of  diabetes  suddenly  assuming  an  intense  form,  since 


DIABETES    MELLITUS.  429 

a  close  enquiry  into  the  patient's  antecedents  generally  re- 
veals the  fact  that  for  some  time  previously  the  patient 
has  been  passing  more  water  than  usual,  or  has  been 
more  thirsty  than  usual,  as  in  a  case  related  by  Professor 
Paget  and  quoted  by  Dickinson  (op.  cit.,  p.  107).  Or  as 
in  another  case  in  which  the  housemaid  remembered  that 
for  some  time  previously  the  water -jugs  in  the  patient's 
room  were  always  empty  of  a  morning,  and  she  could 
only  account  for  the  disappearance  of  the  water  by  his 
having  drunk  it.  In  the  case  already  mentioned  (p.  40), 
if  Dr.  Duncan  had  not  previously  found  traces  of  sugar  in 
the  patient's  urine,  we  might  have  been  led  to  suspect 
that  the  disease  was  recent. 

Owing  to  the  irregular  progress  of  the  disease,  and  the 
long  periods  during  which  it  may  remain  stationary,  and 
be  fairly  controlled  by  treatment,  we  are  unable  to  assign 
a  possible  duration  to  any  given  case,  since  a  mild  form 
may  become  aggravated  any  day,  whilst  an  apparently 
severe  case  may  prove  more  amenable  to  treatment  than 
expected.  In  fact  a  diabetic  patient  may  be  aptly  com- 
pared to  some  tower  undermined,  its  downfall  is  assured, 
but  none  can  tell  when  the  catastrophe  will  occur.  Cases 
of  patients  whose  urine  has  been  continuously  saccharine 
for  more  than  twenty  years  are  on  record,  and  instances 
of  the  disease  lasting  twelve,  fourteen  or  sixteen  years  are 
by  no  means  infrequent.  The  prompt  recognition  of  the 
disease,  owing  to  the  more  routine  employment  of  urinary 
tests  than  was  customary  formerly,  and  the  possibility  of 
thus  detecting  it  at  an  early  stage  before  it  assumes  an 
aggravated  form,  gives  us  better  hopes  of  controlling  its 
progress,  and  giving  the  patient  a  better  expectation  than 
was  previously  possible.  When,  however,  a  case  of  dia- 
betes has  entered  on  a  steadily  downward  course,  and  in 
spite  of  dietetic  restrictions  and  full  doses  of  opium  the 


430  DISEASES    OF    THE    KIDNEY. 

disease  is  not  controlled,  our  prognosis  must  assume  a 
more  gloomy  form,  for  when  the  disease  assumes  a  per- 
manently aggravated  cliaracter,  tlie  patient  usually  dies 
within  two  years  of  the  exacerbation,  frequently  much 
within  this  period. 

Diabetes  may  terminate  fatally  by  exhaustion.  Owing 
to  the  continued  drain  on  the  system,  the  patient  becomes 
reduced  to  a  state  of  extreme  weakness ;  whilst  owing  to 
the  anemia  the  lower  extremities  become  oedematous.  The 
tongue  becomes  red,  raw  and  glazed,  and  the  mouth  and 
throat  covered  with  apthous  patches,  an  incontrollable 
diarrhoea  may  set  in,  which  itself  is  sufficient  to  carry  off 
the  patient  in  his  already  weakened  state,  but  the  end 
usually  comes  through  some  acute  inflammatory  affec- 
tion of  the  lung,  accompanied  with  pulmonary  oedema. 
Or  the  patient  may  succumb  at  an  earlier  stage  of  the 
disease  from  the  development  of  chronic  pneumonia,  which 
at  first  may  run  an  insidious  course,  but  at  length  causes 
a  breaking  down  of  the  lung  tissue,  and  the  formation  of 
phthisical  cavities,  though  rarely  associated  with  the  de- 
position of  tubercle.  Contrasted  with  this  comparatively 
lingering  termination  is  the  somewhat  sudden  death  that 
occurs  by  what  is  known  as  acute  diabetic  coma  (Kiiss- 
maul's  coma).  Many  writers  have  described  this  sudden 
death  as  if  due  to  one  and  the  same  cause,  though  in 
reahty  two  forms  at  least  are  clinically  recognizable. 

In  the  first  form  the  coma  follows  closely  upon  an  attack 
very  much  resembling  collapse  or  syncope,  the  patient 
becomes  suddenly  faint,  often  after  some  complaint  of 
oppression  over  the  region  of  the  heart,  the  extremities  are 
cold,  the  pulse  extremely  weak  but  often  very  rapid  (130- 
140)  at  first,  but  soon  rapidly  falling,  often  great  restless- 
ness but  no  dehrium,  there  is  no  panting  respiration,  and 
the  patient  quietly  sinks  from  exhaustion. 


DIABETES    MELLITUS.  431 

In  the  other  form,  of  which  a  description  has  abeady 
been  given  (p.  30),  the  onset  is  ushered  in  with  gastric 
disturbance,  a  pecuHar  panting  dyspnoea,  followed  by  a 
delirium  of  a  noisy  character  which  is  succeeded  by  pro- 
found coma ;  occasionally  convulsions  of  an  extremely 
violent  character  occur,  in  which  the  patient  may  die  with- 
out becoming  comatose  ;  when  this  happens  the  kidneys 
are  usually  found  diseased  as  well. 

In  both  forms  the  quantity  of  urine  is  considerably 
diminished  at  the  onset  of  the  attack,  in  the  latter 
it  may  be  entirely  suppressed.  In  one  case  I  saw, 
no  urine  was  passed  from  the  onset  of  the  symptoms 
till  death,  a  period  of  fifteen  hours,  when  an  ounce  or 
two  was  found  in  the  bladder  ;  whilst  the  excretion  the 
previous  day  had  amounted  to  120  ounces.  In  this  case 
the  odour  of  acetone  v/hich  had  been  noticeable  in  the 
breath  and  urine  for  some  time  previously,  disappeared 
during  the  two  last  days. 

Such  are  the  modes  by  which  diabetes  proves  fatal. 
The  first  is  undoubtedly  the  natural  termination,  the 
others  are  rather  accidents  by  the  way.  Death  by 
exhaustion  more  usually  results  in  those  cases  which 
have  run  a  uniform  course ;  the  syncopal  form  generally 
occurs  in  those  cases  in  which  emaciation  is  a  marked 
feature  from  the  commencement ;  whilst  diabetic  coma  is 
a  characteristic  termination  of  acute  cases  of  diabetes,  or 
of  cases  previously  existing  in  a  mild  form  that  have 
suddenly  become  acute.  According  to  Dr.  Frederick 
Taylor  (Path.  Soc.  Trans.,  1883)  the  deaths  from  coma 
are  fuUy  one-third  more  numerous  than  deaths  through 
pneumonia  and  phthisis,  and  mostly  occur  in  young  per- 
sons. Dr.  Saundby  (02^.  cit.),  who  has  recently  ably 
reviewed  the  whole  of  our  knowledge  concerning  diabetic 
coma,  has  pointed  out,  that  not  only  is  acetone  frequently 


432  DISEASES    OF    THE    KIDNEY. 

found  in  the  urines  of  patients  wlio  are  not  diabetic,  a 
fact  wliicli  Windle  and  others  had  previously  determined; 
but  also  relates  a  case  of  a  female  patient,  who  died  with 
symptoms  of  "  acetonemia,"  death  taking  place  after  a  con- 
vulsion of  urasmic  character,  but  whose  urine  was  not  sac- 
charine, and  whose  kidneys  were  extensively  disorganised. 
With  regard  to  the  conditions  which  tend  to  induce  this 
peculiar  comatose  condition  in  diabetes,  fatigue,  mental 
emotion,  or  some  inter-current  illness  often  of  a  trivial 
nature,  are  usually  the  chief  exciting  causes.  Constipation 
seems  especially  to  predispose  to  the  condition.  In  one  of 
my  cases,  it  followed  closely  after  the  administration  of  a 
dose  of  castor  oil,  given  for  the  rehef  of  obstinately  con- 
fined bowels ;  in  another  constipation  throughout  had 
been  a  prominent  symptom.  A  high  degree  of  acidity  of 
the  urine  is  often  noticed  prior  to  the  onset  of  diabetic 
coma.  As  already  stated  death  from  coma  is  more  fre- 
quent among  young  persons  than  those  of  more  advanced 
years,  and  according  to  my  experience  occurs  more  fre- 
quently in  the  irregular  and  anomalous  forms  of  diabetes, 
than  in  cases  that  have  run  a  regular,  and  somewhat  a 
protracted,  course. 

To  sum  up,  therefore,  the  present  state  of  our  knowledge, 
concerning  "acetonemia"  or  "  Kiissmaul's  coma,"  we 
may  say : — 

1.  That  acetone,  or  an  acid  body  yielding  acetone,  is 
frequently  present  in  diabetic  urine,  though  also 
noticed  in  some  other  conditions. 

2.  That  acetone,  etc.,  may  be  present  in  the  urine  of 
diabetes  without  coma  necessarily  ensuing,  and  may 
be  absent  from  the  urine  when  that  event  occurs. 
More  commonly,  however,  it  is  noticed  to  be  more 
abundant  just  before  the  onset,  and  to  dechne,  or 
altogether  disappear,  when  the  comatose  symptoms 
develop. 


DIABETES    MELLITUS.  433 

3.  The  urine,  often,  for  some  time  immediately  preced- 
ing an  attack  may  become  extremely  acid ;  and  in 
some  cases  when  the  comatose  symptoms  set  in,  the 
quantity  of  urine  secreted  may  be  considerably 
diminished,  and  the  amount  of  sugar  in  it  consider- 
ably reduced. 

4.  The  symptoms  of  "  acetonsemia "  or  Kiissmaul's 
coma  are  very  similar  to  those  produced  in  animals, 
when  attempts  are  made  to  reduce  the  alkalescence 
of  the  blood,  by  the  injection  of  acids. 

5.  A  toxic   condition   resembling    "  acetonaemia,"    but 

accompanied  with  convulsions,  and  somewhat  par- 
taking of  the  character  of  uremia  has  been  noticed, 
when  both  kidneys  are  extensively  diseased. 
158.  Pathology. — Of  the  numerous  explanations  that 
have  been  offered  to  account  for  the  abnormal  presence  of 
sugar  in  urine,  the  two  most  important  are  those  of  Claude 
Bernard  and  Dr.  Pavy ;  the  others,  being  more  or  less  modifi- 
cations or  refinements  of  these  views.  Thus  Claude  Bernard. 
has  taught  that  whilst  in  health,  the  hepatic  glycogen  is- 
converted  into  sugar,  which  passes  into  the  circulation,  and. 
is  consumed  either  in  the  lungs,  or  utilized  in  the  nutri- 
tion of  the  tissues ;  in  diabetes,  owing  to  an  increased  pro- 
duction of  glycogen,  more  sugar  is  formed  than  can  be 
destroyed  in  the  organism,  and  the  overplus  is  discharged 
with  the  urine.  Or  else  without  any  increased  activity  of 
the  glycogenic  function,  the  normal  amount  of  sugar  is- 
not  consumed  in  the  organism,  and  is  consequently  ex- 
creted. Dr.  Pavy,  on  the  contrary,  considers  that  in  the 
normal  condition,  httle  or  no  sugar  passes  from  the  liver 
into  the  circulation,  and  that  instead  of  being  a  sugar 
forming  organ,  the  liver  is  a  sugar  assimilating  organ^ 
and  it  is  only  when  this  function  of  assimilating  sugar 
(converting  it  into  fat  most  probably)  is  interrupted,  that 

FF 


434  DISEASES    OF    THE    KIDNEY. 

sugar  appears  in  the  urine .  I  believe  Dr.  Pavy's  explana- 
tion to  be  tbe  one  nearest  the  truth.  The  strongest 
objection  that  has  been  raised  against  it  is,  that  if  sugar 
be  injected  continuously  into  the  blood,  in  small  quantities 
so  that  the  percentage  present  does  not  much  exceed  0-2, 
the  urine  does  not  become  saccharine.  But  in  answer  to 
this  objection  I  think  it  sufficient  to  observe,  that  if  the 
exjperiment  is  performed  in  a  healthy  animal,  the  condi- 
tions are  not  the  same  as  those  that  are  claimed  to  exist 
in  diabetes,  in  which  the  power  of  assimilating  sugar  is 
lost.  For  we  must  not  suppose  that  the  power  of  assimi- 
lating sugar  is  limited  to  the  hepatic  cells,  since  undoubt- 
edly all  tissues  whose  cells  contain  glycogen  (and  this 
is  especially  the  case  with  muscular  tissue)  would  possess 
the  same  power.  Therefore,  if  sugar  pass  into  the  circu- 
lation of  a  healthy  animal,  it  would  be  assimilated  by  the 
tissues  and  liver.  That  this  is  so,  may  fairly  be  assumed 
by  the  fact  that  a  small  quantity  of  sugar  passes  daily 
from  the  intestines,  by  the  lacteals  and  thoracic  duct, 
directly  into  the  circulation  without  first  having  gone 
round  by  the  liver,  as  this  sugar  does  not  appear  in  the 
urine,  we  may  reasonably  infer  that  it  is  assimilated  by 
the  organism.  Another  objection  raised  by  the  opponents 
of  Dr.  Pavy's  theory  is,  that  the  amount  of  sugar  found  in 
the  hepatic  vein,  is  greater  than  in  other  vessels  of  the 
body,  and  they  have  argued  from  this  that  sugar  is 
normally  formed  by  the  liver,  and  passes  into  the  circu- 
lation, but  Dr.  Pavy  {op.  cit.)  has,  I  think,  conclusively^ 
answered  this  objection,  by  showing  that  the  original 
experiments  on  which  the  objection  is  founded  were 
faulty,  and  that  when  the  experiment  is  performed  with 
care,  the  blood  of  the  hepatic  vein  is  not  sensibly  richer 
than  that  of  the  other  vessels  of  the  body.  These  objec- 
tions being  disposed  of,  I  think  we  may  assume  that  the 


DIABETES    MELLITUS.  435 

primary  cause  of  saccharine  diabetes  lies  in  the  disturbance 
of  the  glycogenic  function,  by  ivhich  the  sugar  assimilating 
IJOwers  of  the  liver,  and  2^robably  also  of  all  glycogen-yielding 
tissues,  are  interrupted,  and  that  sugar,  instead  of  being 
utilized  by  the  organism,  is  yassed  out  of  the  body  by  the 
kidneys. 

Tlie  next  question  that  arises  is,  what  causes  this  in- 
terruption of  the  glycogenic  function  ?  Most  authorities 
are  agreed  that  it  depends  upon  some  alteration  of 
the  circulation  in  the  liver  brought  about  through  the 
influence  of  the  nervous  system.  The  divergence  of 
opinion  is  whether  this  alteration  consists  in  an  active 
or  passive  congestion;  whilst  Dr.  Pavy  {op.  cit.)  be- 
lieves that  mere  congestion  of  the  liver  is  not  an  effi- 
cient cause,  and  that  there  must  also  be  an  afSux  of 
blood  not  properly  venous.  Dr.  Pavy  has  brought  for- 
ward many  facts  to  show  that  venous  blood  is  favourable, 
and  oxygenated  blood  is  unfavourable,  for  the  accumula- 
tion of  glycogen,  and  since  there  is  no  organ  in  the  body 
supplied  with  venous  blood  to  such  an  extent  as  the  liver, 
nowhere  does  glycogen  exist  to  a  like  extent.  Now  in 
diabetes.  Dr.  Pavy  maintains,  the  blood  is  imperfectly 
venous  owing  to  the  dilatation  of  the  arteries  of  the  chylo- 
poietic  viscera  brought  about  by  vaso -motor  paralysis; 
just  as  in  the  well-known  experiment  on  the  rabbit's  ear, 
when  section  of  the  sympathetic  shows  such  a  modification 
in  the  circulation,  that  the  blood  when  it  reaches  the 
veins  has  still  an  arterial  character.  The  bright  red  ap- 
pearance of  the  tongue  so  often  noticed  in  diabetes,  also 
suggests  that  the  blood  is  flowing  through  the  organ, 
without  being  properly  deprived  of  its  arterial  character. 

Dr.  Pavy  {Path.  Soc.  Trans.,  1883)  has  also  recently 
adduced  another  interesting  fact,  to  prove  that  diabetes 
is  caused  by  the  afflux  of  blood  not  properly  venous.     He 

ff2 


436  DISEASES    OF    THE    KIDNEY. 

has  shown  that  while  all  the  ferments  of  the  body  can 
only  bring  starch  into  the  condition  of  maltose,  or  a  dextrin 
of  low  cupric  oxide  reducing  power,  yet  the  principle 
found  in  diabetic  urine  is  glucose.  Now  under  ordinary 
circumstances  when  the  blood  of  the  portal  vein  was 
thoroughly  venous  it  contained  maltose  and  dextrin, 
which  were  in  turn  converted  into  glycogen,  which  accu- 
mulated and  was  assimilated  in  the  liver  ;  but  when  the 
blood  was  experimentally  rendered  imperfectly  venous 
glucose,  and  not  maltose,  was  the  result.  Accordingly 
Dr.  Pavy  thinks  that  the  interruption  of  the  glycogenic 
function  is  induced  by  a  vaso -motor  paralysis  which  causes 
dilatation  of  the  arteries  of  the  chylo-poietic  viscera,  by  which 
means  the  liver  is  supplied  ivith  blood  imperfectly  venous. 

This  brings  us  to  the  nature  of  the  nervous  lesion  in 
diabetes.  Owing  to  the  fact,  first  pointed  out  by  Claude 
Bernard,  that  puncture  of  the  medulla  oblongata  at  the 
diabetic  centre,*-'  was  followed  by  discharge  of  saccharine 
urine,  pathologists  have  sought  for  lesions  in  that  neigh- 
bourhood to  explain  the  phenomena  of  diabetes.  Dr. 
Dickinson  has  been  foremost  in  this  field  of  investigation 
and  has  described  and  exhibited  microscopical  specimens 
showing  chiefly  the  following  morbid  changes  in  the  brain 
in  diabetes,  viz.,  dilatation  of  the  blood  vessels,  extravasa- 
tion of  blood  in  small  amount,  enlargement  of  perivas- 
cular spaces,  and  alterations  in  the  perivascular  sheaths 
and  nervous  matter  bounding  the  cavities.  It  was  upon 
the  nature  of  these  lesions  that  the  Debate  in  1882  at  the 
Pathological  Society,  "  On  the  Morbid  Anatomy  of  Dia- 
betes," chiefly  turned;   when  the  Committee,  appointed  to 

*  This,  according  to  Eckhard,  in  the  rabbit,  is  4  or  5  mm.  above 
the  point  of  the  calamus  scriptorius  for  the  lower  limit,  and  1  or  2 
mm.  below  the  corpora  qnadrigemina  for  the  higher  (Foster's 
Pliysioloyy). 


DIABETES    MELLITUS.  437 

investigate  the  changes  exhibited  by  specimens  of  the 
nervous  centres  in  cases  of  diabetes,  submitted  by  vari- 
ous exhibitors,  reported  that  they  failed  to  find  in  the 
specimens  "  any  changes  which  could  be  regarded  as  ex- 
clusively or  constantly  associated  with  diabetes."  The 
same  may  be  said  with  regard  to  gross  lesions,  such  as 
intra-cranial  growths,  aneurisms,  etc.,  involving  the  ner- 
vous centres.  It  has  also  been  suggested  that  it  is  not 
necessary  for  the  vaso- motor  centre  itself  to  be  the  seat 
of  lesion  ;  since  the  vaso-motor  nerves  may  be  morbidly 
affected  at  some  point  between  the  centre  and  the  liver, 
or  there  may  be  reflex  irritation  like  the  glycosuria  in- 
duced by  acting  on  the  sciatic  nerve,  or  by  irritation  of 
the  liver-tissue  itself.  Experimentally  it  has  been  shown, 
that  glycosuria  can  be  induced  by  acting  through  the 
vaso-motor  sympathetic  system ;  whilst  specimens  show- 
ing changes,  usually  of  a  chronic  inflammatory  nature, 
affecting  the  sympathetic  ganglia,  in  diabetes,  have  been 
frequently  brought  forward.  The  best  description  of  these 
changes  will  be  found  in  the  Pathological  Society's  Transac- 
tions for  the  current  year,  in  a  paper  read  December  16th, 
1884,  by  Dr.  Hales  White,  describing  the  microscopical 
examination  of  the  sympathetic  in  diabetes.  These 
changes,  however,  are  certainly  not  constant,  nor  exclu- 
sively met  with  in  diabetes. 

Our  present  knowledge,  therefore,  with  regard  to  the 
action  of  the  nervous  system  in  diabetes  amounts  to 
this.  That  whilst  no  constant  or  exclusive  pathological 
changes  of  the  nervous  system  are  found  post-mortem 
in  diabetes,  yet  everything  points  to  a  disturbance  act- 
ing through  the  vaso-motor  nervous  system.  This  may 
originate  in  the  vaso-motor  centre  itself,  or  it  may  be  in- 
duced in  a  reflex  manner,  or  through  the  sympathetic 
vaso-motor  nerves.      Nor  need  the  disturbance  necessarily 


438  DISEASES    OF    THE    KIDNEY. 

arise  from  a  demonstrable  lesion,  since  in  many  cases  it  is 
probable  that  the  circulation  of  blood  charged  with  some 
morbid  agent  may  cause  the  disturbance,  either  by  irri- 
tating the  vaso-motor  system  at  the  centre,  or  at  their 
peripheral  terminations  on  the  hepatic  vessels. 

The  bloodin  diabetes  often  contains  as  much  as  0*5  per  cent, 
of  sugar.  In  most  cases  there  is  a  demonstrable  increase 
in  the  amount  of  fatty  matter  present,  whilst  in  some  cases 
the  increase  is  so  great  as  to  give  the  blood  a  lactescent 
apx^earance  (lijJCBmia) ;  it  is  in  these  cases  that  the  fat 
emboli  originally  discovered  by  Hamilton  and  Saunders 
{Edin.  Med.  Jour.,  July,  1879)  in  the  vessels  of  the  lungs 
and  brain  are  found.  Professor  Gamgee  (o^?.  cit.,  p.  172) 
has  given  an  analysis  of  the  blood  in  this  lactescent  con- 
dition, which  shows  that  the  total  fatty  matters  were 
13'55  per  1000,  of  which  9*86  parts  were  neutral  fats, 
1-55  lecithin,  and  2-14  cholesterin.  The  nature  of  this 
fatty  increase  is  not  well  understood,  many  have  thought 
it  was  due  to  admixture  of  acetone  with  the  blood,  but 
shaking  up  blood  with  acetone  will  not  give  the  appear- 
ance ;  moreover,  it  is  doubtful  whether  acetone  exists 
at  all  as  acetone  in  the  blood,  but  is  derived  from  a 
fatty  acid.  The  fat  emboli,  moreover,  are  probably 
not  formed  during  life,  but  are  caused  by  the  coale- 
scence of  the  fatty  matters  in  the  blood  after  death.  I 
have  advanced  the  explanation  [Path.  Soc.  Trans.,  1883) 
that  the  increase  of  fatty  matter  so  often  observed  in 
diabetes,  not  only  in  the  blood,  but  in  the  muscles,  the 
hver  cells,  and  renal  epithelium,  is  aUied  to  similar 
changes  produced  by  phosphorus  poisoning,  or  poisoning 
by  the  injection  of  mineral  acids,  bile  acids,  or  oxalic  and 
tartaric  acids,  into  the  blood  of  animals,  both  as  regards, 
the  chnical  symptoms  as  well  as  the  pathological  changes, 
and  that  the  condition  in  diabetes  is  not  brought  about  by 


DIABETES    MELLITUS.  439 

the  presence  of  acetone,  but  by  aceto-acetic  acid,  from 
wbicli  the  acetone  in  urine  is  probably  derived.  The 
discovery  by  Minkowski  {op.  cit.}  of  pseudo-  or  /3-oxy- 
butyric  acid  which  is  capable  of  breaking  up  into  aceto- 
acetic  acid  in  the  urine  of  diabetic  patients,  strengthens 
this  view ;  whilst  Henry  (op.  cit.)  has  shown,  by  injecting 
acids  into  the  blood  of  herbivorous  animals,  that  my  state- 
ment, made  at  the  debate  at  the  Pathological  Society  in 
1882,  with  regard  to  the  similarity  of  the  symptoms  of 
acute  diabetic  coma  and  that  of  acid  poisoning,  was  quite 
correct.  It  has  been  urged,  however,  against  this  view, 
as  well  as  that  of  Professor  Hamilton's,  who  believes  that 
the  symptoms  of  diabetic  coma  are  occasioned  by  the  fat 
emboli,  that  many  cases  of  diabetic  coma  occur  in  which 
no  increase  of  fat  in  the  blood  takes  place,  nor  any  fat 
emboli  can  be  discovered.  But  this  objection  is  fairly  met 
by  pointing  out  that  there  are  at  least  two  forms  of 
sudden  death  in  diabetes,  both  spoken  of  as  by  coma ;  but 
one,  and  that  which  in  my  experience  is  the  most  fre- 
quent, is  rather  due  to  collapse  from  cardiac  syncope  than 
to  a  toxic  condition  brought  about  by  changes  in  the 
blood ;  and  in  this  form  neither  an  increase  of  fat  in  the 
blood  nor  fat  emboli  would  probably  be  observed.  More- 
over, if  the  toxic  condition  of  the  blood  is  the  cause  of  the 
coma  and  of  the  fatty  changes,  it  may  happen  in  some 
cases  when  the  development  or  accumulation  of  the  toxic 
agent  occurs  suddenly,  and  the  poison  is  present  in  large 
quantity,  that  death  may  occur  before  the  fatty  changes 
have  time  to  develop. 

"With  regard  to  the  changes  in  the  other  organs,  the 
liver  has  been  described  by  the  older  writers  as  somewhat 
enlarged,  dark  coloured,  and  of  tough  consistence.  Dr. 
Dickinson  has  described  overgrowth  and  crowding  of  the 
epithehum  as  often  seen,  along  with  frequent  evidence  of 


440 


DISEASES    OF    THE    KIDNEY. 


liyperfemia.  In  the  majority  of  cases,  however,  no  special 
changes  can  be  observed,  and  the  liver  instead  of  being 
enlarged  and  tough,  may  be  small  and  soft ;  in  some  rare 
cases,  as  in  the  one  described  by  Professor  Gamgee  in  his 
work  on  Animal  Chemistry,  the  liver  cells  had  undergone 
changes  analogous  to  those  of  acute  yellow  atrophy. 

The  j^ancreas  has  been  so  frequently  found  in  a  morbid 
state  in  diabetes,  that  some  relationship  has  been  supposed 
to  exist  between  derangements  of  that  organ  and  the  dis- 
order; but  disease  of  the  pancreas  is  not  a  constant  pheno- 
menon, and  is  also  often  found  to  exist  without  diabetes.  The 
changes  that  have  been  observed,  are  fibrosis  with  atrophy 
of  the  glandular  parenchyma ;  cancer  ;  atrophy  following 
occlusion  by  concretions  ;  fatty  changes,  an  interesting 
account  of  a  case  of  which  is  given  by  Dr.  Frederick 
Taylor  {Path.  Soc.  Trans.,  1883)  in  which  the  pancreas 
seemed  reduced  to  a  mere  lump  of  fat. 

The  lungs. — The  most  frequent  morbid  conditions  observed 
are  pneumonic  and  phthisical.  According  to  Dr.  Stephen 
Mackenzie  {Path.  Soc,  Trans.,  1883)  the  process  appears  to 
begin  as  a  (in  a  sense)  croupous  pneumonia,  with  some 
thickening  of  the  alveolar  walls  ;  the  exuded  and  proli- 
ferated contents  of  the  air  vesicles  and  the  alveolar  walls 
then  undergo  a  necrotic  process,  the  vessels  become  ob- 
literated, and  the  necrosed  part  crumbles  away.  The 
"  obliterative  arteritis"  of  Friedlander  can  be  well  seen  in 
many  of  the  alveolar  blood  vessels.  The  occurrence  of 
giant  cells  is  rare.  Tubercular  phthisis  is,  however,  not 
at  all  common  in  diabetes. 

In  the  heart,  the  microscopic  changes  usually  resemble 
those  met  with  in  persons  dying  from  chronic  disease, 
though  in  some  instances,  in  cases  in  which  the  death  was 
sudden,  fatty  degeneration  and  accumulation  had  occurred 
in  the  muscular  tissue. 


DIABETES    MELLITUS.  441 

The  kidneys  are  generally  enlarged  and  liypersemic,  and 
the  epithelium  somewhat  granular.  In  the  majority  of 
cases  the  peculiar  "  dropsical  degeneration  "  of  the  epi- 
thelium first  mentioned  by  Cantani  can  be  observed. 
This  change  which  is  confined  to  the  collecting  tubes, 
consists  in  a  vesicular  condition  of  the  cells  which  be- 
come swollen  and  translucent,  and  look  as  if  they  had 
been  washed  out,  only  the  framework  being  left ;  a  good 
representation  of  this  condition  is  given  by  Mackenzie 
in  plate  xxiv.,  Path.  Soc.  Trans.,  1883.  Frerichs  [Zeit. 
fur  Klinische  Medicin.,  Bd.  vi.,  1883)  by  hardening 
sections  in  absolute  alcohol,  and  then  keeping  them 
for  a  short  time  in  a  dilute  solution  of  potassium-  iodide 
and  iodine,  has  been  able  to  demonstrate  by  means  of  the 
dark  mahogany  stain,  the  presence  of  glycogen  in  the 
renal  epithelium  ;  this  seems  most  abundant  in  Henle's 
loops,  and  to  be  present  in  mild  as  well  as  in  severe  cases 
of  diabetes. 

159.  Treatment. — The  treatment  of  diabetes  is  almost 
a  matter  of  restricted  diet,  the  principle  question  in  any 
given  case  being  whether  the  withdrawal  of  starchy  or 
saccharine  food  should  be  absolute  or  partial.  For  twenty- 
four  hours  after  sugar  has  been  first  detected  in  the 
urine  the  patient  should  be  allowed  to  continue  his  usual 
diet,  whilst  the  whole  of  the  urine  passed  during  that 
period  should  be  collected,  carefully  measured,  and  the 
amount  of  sugar  and  urea  excreted  exactly  determined. 
The  patient  should  then  be  placed  upon  a  diet  from  which 
every  article  containing  the  slightest  trace  of  starch  or 
sugar  must  be  rigidly  excluded  (see  Appendix  II.).  After 
a  fortnight  of  this  diet  the  urine  must  be  again  collected 
and  the  amount  of  sugar  and  urea  determined.  In  mild 
cases  it  will  usually  be  found  that  the  sugar  has  either 
disappeared  or  at  all  events  is  greatly  reduced  in  quantity. 


442  DISEASES    OF    THE    KIDNEY. 

In  more  severe  cases  the  reduction  tliough  marked  'will  not 
be  so  considerable.  Supposing  the  sugar  to  have  alto- 
gether disappeared,  then  no  other  treatment  will  be 
requh'ed,  but  a  continuance  of  the  diet  for  at  least  two 
months,  after  which  time  if  the  urine  continues  free  from 
sugar  a  very  gradual  return  to  the  ordinary  diet  may  be 
attempted.  If,  however,  the  sugar  does  not  entirely  dis- 
appear from  the  urine  under  dietetic  restriction,  then 
recourse  must  be  had  to  opium.  This  drug  has  long  been 
employed  in  the  treatment  of  diabetes.  It  is  generally 
supposed  that  Dr.  Pelham  Warren  first  recommended  it 
for  the  treatment  of  diabetes,  but  to  Paracelsus  (1527) 
undoubtedly  belongs  the  credit,  for  he  gives  the  following 
prescription  for  the  treatment  of  the  disease :  "  5;  de  hquori- 
bus  papaveris  |  ss,  lolii  3  j,  camphoree  S  j,  rosarum planta- 
ginis  solatii  3  iss  ;  reduc  informamliquidam."  Under  its 
administration  the  amount  of  sugar  is  sensibly  diminished, 
and  in  mild  cases  the  excretion  may  be  altogether  arrested, 
even  though  saccharine  articles  are  taken.  Diabetic 
patients  are  exceedingly  tolerant  of  the  drug,  and  large 
quantities  can  be  taken  by  them  without  inducing  any  of 
the  unpleasant  symptoms  usually  attendant  on  its  ad- 
ministration, nor  do  they  seem  to  acquire  a  craving  for  the 
drug,  so  noticeable  when  employed  for  the  relief  of  other 
diseases.  Under  its  influence  the  urinary  excretion  is 
considerably  diminished,  the  appetite  and  thirst  restrained, 
the  neuralgic  pains  disappear,  and  the  patient  gains  in 
weight  and  strength.  Objections  have  been  raised  to  its 
use,  that  it  enhances  the  tendency  to  diabetic  coma,  but  a 
reference  to  published  cases  does  not  bear  this  out,  and 
my  own  experience  is  contrary  to  it ;  since  in  the  instances 
of  diabetic  coma  I  have  seen,  in  the  majority  opium  had 
never  been  administered,  as  they  were  cases  of  disease 
running  a  mild  course,  not  requiring  opium  treatment,  but 


DIABETES    MELLITUS.  443 

•which  had  suddenly  become  aggravated.  The  opium  treat- 
ment of  diabetes  is  chiefly  called  for,  when,  after  a  fair  trial 
of  restricted  diet,  sugar  still  continues  to  be  excreted  in  the 
urine.  In  these  cases  the  opium  should  be  given  in  gradu- 
ally increasing  doses  till  the  sugar  entirely  disappears,  or 
till  in  spite  of  an  increased  quantity  of  opium  being  given, 
no  further  reduction  in  the  amount  of  sugar  excreted 
takes  place ;  before  this  is  effected,  however,  very  con- 
siderable quantities  of  the  drug  have  often  to  be  employed. 
Thus,  I  have  a  patient  at  present  under  my  care  who  for 
the  past  two  years  has  taken  every  night  a  quantity  of 
opium  equivalent  to  half  an  ounce  of  liquor  opii  sedativus. 
Except  in  controlling  the  disease  this  quantity  of  opium 
seems  to  have  no  effect  on  his  general  health,  his  weight 
and  strength  are  well  maintained,  he  conducts  his  business 
with  energy  and  vigour,  he  digests  his  food  well,  which  is 
restricted,  except  as  regards  a  daily  allowance  of  four 
ounces  of  bread.  By  means  of  this  dose  of  opium  the 
amount  of  sugar  in  his  urine  is  reduced  to  a  mere  trace, 
but  whenever  an  attempt  is  made  to  reduce  the  quantity 
of  opium,  then  the  sugar  is  at  once  increased,  and  that  too 
out  of  all  proportion  to  the  reduction  made.  It  is  in- 
teresting to  record  that  though  he  has  taken  this  quantity 
of  opium  for  two  years,  he  has  not  had  further  to  increase 
the  amount. 

Opium  may  also  be  used  in  diabetes,  either  when, 
in  a  mild  form  after  the  continuous  employment  of  re- 
stricted diet  the  sugar  has  disappeared,  an  experimen- 
tal return  is  made  to  ordinary  food ;  or  in  cases  when 
owing  to  the  state  of  the  patient's  general  health,  or  his 
disgust  at  a  diet  almost  entirely  animal,  it  is  impossible 
to  enforce  absolute  restriction  as  regards  starchy  and  sac- 
charine articles  of  food,  and  a  relaxation  must  be  permit- 
ted.  "When  the  administration  of  opium  is  determined  on. 


444  DISEASES   OF    THE    KIDNEY. 

questions  arise  as  regards  the  quantity  and  the  frequency 
of  administration.  Some  give  opium  in  small  and  often 
repeated  doses.  I  prefer,  however,  the  administration  of 
one  large  and  sufficient  dose  taken  at  hedtime.  As  regards 
the  amount  of  the  dose  the  requkement  varies  with  the 
individual,  and  experience  has  taught  me  that  each  diabe- 
tic has  his  own  capacity  for  opium  which  we  have  to  find 
out.  We  should  therefore  begin  with  a  moderate  dose, 
say  a  grain,  and  increase  this  till  a  point  is  reached  at 
which  the  sugar  either  disappears,  or  is  no  longer  reduced 
by  increasing  the  quantity  of  the  drug  ;  when  this  point  is 
reached  I  have  often  found  that  no  further  increase  is 
requu-ed  for  a  long  time.  Various  preparations  of  opium 
have  been  recommended  instead  of  the  crude  drug,  or  its 
tincture.  Of  these,  codeia,  introduced  by  Dr.  Pavy  is  the 
chief;  but  the  solution  of  hi-meconate  of  morphia  (Squire), 
and  nepenthe  (Ferris  and  Co.),  are  also  very  efficient. 
These  ^^reparations  are  said  to  have  the  advantage  of  not 
disordering  digestion,  nor  causing  headache  or  constipa- 
tion, like  the  preparations  of  crude  opium. 

When  it  is  determined  to  allow  a  shght  relaxation  in 
the  matter  of  diet,  we  have  to  consider  what  article  we 
shall  commence  with.  And  undoubtedly  bread  is  what 
diabetics  most  crave  for,  besides  which  bread  is  not  wholly 
farinaceous.  To  begin  with  I  usually  allow  2  oz.  of 
bread  for  breakfast,  and  another  2  oz.  with  the  last  meal 
of  the  day,  so  that  twelve  full  hours  intervene  between 
each  introduction  of  starchy  food.  With  regard  to  bread 
a  medical  friend  who  suffers  from  diabetes,  tells  me  that 
whereas  a  small  quantity  of  stale  bread  always  renders 
his  urine  saccharine,  the  same  quantity  of  new  bread  does 
not ;  he  explains  this  by  saying  that  stale  bread  being 
more  easy  of  digestion,  the  starch  is  more  quickly  con- 
verted into  sugar,  and  reaches  the  hver  more   rapidly, 


DIABETES    MELLITUS.  445 

wliereas  new  bread  is  not  so  quickly  acted  on,  and  the 
sugar  is  presented  more  slowly,  so  that  the  glycogenic 
function  is  not  stimulated  to  the  same  degree.  The  hard 
chippy  fragments  of  dry  toast  seem  to  act  in  the  same 
way.  The  relaxation  of  diet,  however,  must  be  carefully 
watched,  since  in  some  cases  the  most  trivial  transgres- 
sion will  bring  back  the  disease  in  full  force.  Eollo  says, 
he  has  known  "  half  a  biscuit,  such  as  are  sold  three  for 
a  penny,"  to  bring  back  the  disease  in  full  force,  though 
previously  sugar  had  been  sometime  absent  from  the  urine. 
Of  all  articles  of  food  potatoes  are  the  most  injurious,  not 
only  from  their  containing  more  starch,  but  from  its  being 
cooked,  and  is  therefore  in  an  easily  assimilable  form  ; 
for  this  reason,  they  should  never  under  any  circumstances 
be  permitted  to  either  diabetic  or  glycosuric  patients.  Some 
diabetics  are  more  tolerant  than  others  of  saccharine 
food,  especially  of  fruit  sugars.  An  eminent  chemist 
who  has  suffered  for  some  years  from  diabetes  has  ob- 
served, that  he  may  take  in  moderation,  jam,  marmalade, 
or  any  of  the  red  fruits,  without  greatly  increasing  the 
sugar  in  his  urine,  but  the  slightest  particle  of  starch 
taken  at  once  aggravates  the  tendency.  With  regard  to 
the  insistance  of  a  continuance  of  a  restricted  diet  in  those 
cases,  in  which  after  all  starchy  and  saccharine  food  has 
been  cut  off,  sugar  still  appears  in  considerable  quantities 
in  the  urine,  I  have  found  that  after  no  further  reduction 
is  possible,  it  is  advisable  in  order  to  maintain  the  patient's 
general  health  to  permit  a  relaxation,  such  as  a  small 
quantity  of  bread,  and  the  use  of  such  vegetables  that  con- 
tain only  but  little  sugar  or  starch  (these  are  marked  with 
an  asterisk  in  the  diet  list  in  the  appendix) ,  always  how- 
ever, excluding  potatoes.  When  this  relaxation  is  made 
it  is  necessary,  however,  generally  to  administer  opium 
in  some  form,  or  increase  the  dose  if  it  has  already  been 
given. 


446  DISEASES    OF    THE    KIDNEY. 

There  is  only  one  condition  under  which  saccharine 
urine  is  passed,  which  is  not  benefitted  by  an  animal  diet, 
and  that  is  the  so-called  *'  gouty  glycosuria."  Patients 
suffering  from  this  condition  are  usually  corpulent  and 
plethoric,  have  a  tendency  to  piles,  and  to  uric  acid  gravel, 
and  although  their  urine  is  saccharine  they  rarely  show 
any  of  the  ordinary  symptoms  of  diabetes.  These  are  the 
cases,  and  they  are  tolerably  numerous,  in  which  the  skim 
milk  diet  usually  agrees  so  well,  not  because  there  is  any 
special  merit  in  skim  milk,  which  contains  at  least  3" 5  per 
cent,  of  sugar,  but  simply  because  whilst  on  it,  habits  of 
gross  feeding  are  checked,  and  the  patients  are  kept  in  a 
state  of  semi- starvation.  Even  in  cases  of  diabetes,  in 
which  meat  forms  the  chief  staple  of  diet,  the  amount 
should  be  restricted  within  moderate  limits.  Diabetics 
too  often  think  that  as  they  are  restricted  in  other  articles 
of  food,  they  are  bound  to  make  up  the  deficiency  by  eat- 
ing enormous  quantities  of  animal  food  (see  also  Ap- 
pendix II.). 

Ought  diabetic  cases  to  be  allowed  alcohol ;  the  answer 
to  this  question  must  be  that  it  depends  upon  the  indivi- 
dual case.  Some  diabetics  are  singularly  tolerant  of 
alcohol,  and  it  seems  to  have  little  or  no  influence  in  the 
excretion  of  sugar ;  others  again  complain  that  it  increases 
the  diuresis,  adds  to  their  thirst  and  makes  them  feel 
generally  uncomfortable.  If  permitted  it  should  be  in  as 
a  dilute  a  form  as  possible,  and  only  taken  with  meals,  for 
this  purpose  the  light  Bavarian  or  Vienna  beers  now  so 
popular,  brut  champagne,  dry  sherry,  or  a  little  whisky 
and  water  may  be  permitted.  Burgundy  and  dry  port 
may  be  given  if  there  is  great  debility. 

Next  to  diet  and  opium,  the  diabetic  patient  will  receive 
the  most  benefit  from  the  constant  use  of  the  vajjour  hath. 
Willis  (op.  cit.)  pointed  this  out  years  ago,  and  quoted 


DIABETES    MELLITUS.  447 

several  cases  in  wliieh  undoubted  benefit  resulted.  It  not 
only  relieves  the  diabetic  pains  and  the  weariness,  but 
diminishes  for  a  time  the  amount  of  sugar  as  much  as  20, 
30  or  even  50  per  cent.  It  is  strange  that  such  an  effica- 
cious aid  to  our  treatment  should  have  been  persistently- 
overlooked  by  recent  English  writers  on  the  subject.  M. 
Campardon  [Progres  Medicale,  April,  1884)  also  reports 
favourably  of  air  douches.  In  one  case  after  eighteen 
douches,  the  sugar  fell  from  77*4  to  36*65  grms.,  and  in 
another  from  102  to  68  grms.  The  douche  is  applied  for 
five  or  ten  minutes  over  the  cervical  and  upper  dorsal 
region,  when  it  causes  pallor  of  the  skin,  and  a  consider- 
able fall  of  temperature.  When  neither  the  vapour  bath 
nor  air  douche  is  available,  then  the  cold  pack  may  be 
tried  with  advantage. 

Alkalies  often  prove  serviceable  in  diabetes,  probably 
from  their  oxidizing  influence  and  diminishing  acidity 
in  the  intestinal  canal.  For  this  purpose,  I  usually 
prescribe  about  twenty  grains  of  bicarbonate  of  soda, 
ten  grains  of  ]3hosphate  of  soda,  five  grains  of  carbo- 
nate of  ammonia,  in  a  draught,  to  be  taken  two  hours 
after  food.  Their  use  is  specially  indicated  in  "gouty 
glycosuria." 

Acids  with  or  without  pepsin  are  useful  in  aiding  diges- 
tion. Dr.  Wilks  [Medical  Times  and  Gazette,  March,  1884) 
recommends  the  use  of  mineral  acids  with  nux  vomica, 
which  he  thinks  beneficial,  not  merely  by  their  action  on 
digestion,  but  also  from  a  positive  effect  on  the  glycogenic 
functions.  Half  a  drachm  of  diluted  hydrochloric  acid  in 
half  a  tumbler  of  water,  flavoured  with  tincture  of  orange- 
peel  taken  immediately  after  a  meal,  often  proves  an  ex- 
cellent digestive. 

With  regard  to  other  remedies  iodoform  has  been  recom- 
mended by  Moleschott   {Wien.  Med.   Wochenschrift,  Nov. 


448  DISEASES    OF    THE    KIDNEY. 

1882)  and  other  physicians,  it  undoubtedly  checks  the  ex- 
cretion of  sugar,  but  is  inferior  in  its  action  to  opium, 
whilst  owing  to  the  accumulative  properties  of  the  drug, 
its  administration  should  not  be  ventured  on  ;  not  even  if 
we  follow  Post's  suggestion  [Archives  of  Medicine,  New  York, 
April,  1884),  and  systematically  interrupt  the  administra- 
tion, since  even  in  small  doses  there  are  cases  in  which  it 
may  produce  anaemia  and  fatty  degeneration.  Arsenic,  bro- 
mide of  arsenic,  phosphorus,  the  salicylates,  calcium  sulphide, 
and  numerous  other  drugs  have  been  recommended  for  the 
treatment  of  diabetes,  and  instances  of  their  beneficial 
action  have  been  recorded,  on  looking  through  the  cases, 
however,  I  have  come  to  the  conclusion  that  the  good 
results  depend  either  on  strict  dietetic  regulation,  having 
been  employed  as  well,  or  that  the  cases  were  not  ones 
of  true  diabetes,  but  only  .temporary  glycosuria.  Thus 
arsenic  or  the  sahcylates  would  be  found  serviceable  in 
malarial  glycosuria,  and  phosphorus  in  conditions  of  ex- 
haustion and  weakness. 

The  hygienic  treatment  of  diabetes  is  fulfilled  by  the 
careful  regulation  of  the  diet ;  by  keeping  the  patient 
warmly  clad,  and  sheltered  from  cold  damp  winds ;  by 
encouraging  moderate  exercise  and  cheerful  employment, 
but  avoiding  all  fatigue  bodily  or  mental,  and  the  avoid- 
ance of  all  long  railway  journeys ;  by  change  of  air,  especi- 
ally, to  the  sea-side.  Great  benefit,  especially  in  mild  cases, 
is  often  experienced  by  the  use  of  Carlsbad  and  Vichy 
waters,  but  owing  to  the  long  railway  journeys  I  advise 
patients  to  take  these  at  home,  or  else  use  the  mineral 
waters  of  the  Hot  Wells  Clifton,  or  Bethesda,  in  England. 
Finally,  with  regard  to  the  so-called  modes  of  cure.  The 
"  skim  milk  system  of  diet  is  only  useful  in  cases  of  gouty 
glycosuria,"  in  other  forms  of  saccharine  diabetes  it  does 
undoubted  harm.     The  ^^ sugar"  treatment  is  altogether 


DIABETES    MELLITUS.  449 

fallacions  and  has  been  universally  condemned.  Tlie  ren- 
net or  pepsine  cure  can  only  be  obtained  when  the  obser- 
vance of  a  most  rigid  abstention  of  starch  and  sugar  in 
any  form  is  enforced  as  well.  The  lactic  acid  treatment 
as  recommended  by  Cantani  has  been  given  a  fair  trial  by 
numerous  physicians,  but  the  results  obtained  have  been 
far  from  satisfactory,  so  that  it  has  been  practically  aban- 
doned ;  though  in  some  cases  of  glycosuria,  dependent 
apparently  on  malassimilation  in  the  intestinal  canal,  it 
has  done  good. 

With  regard  to  the  treatment  of  diabetic  coma  many 
suggestions  have  been  made,  but  as  yet  all  means  have 
proved  useless.  Some  temporary  improvement  seems  to 
have  followed  the  injections  of  a  weak  solution  of  sodium 
phosphate  and  sodium  chloride  into  the  veins  in  a  case 
reported  by  Dr.  Frederick  Taylor,  but  it  has  never  proved 
successful.  Perhaps  more  encouraging  results  might  be 
obtained  by  combining  venesection  with  intravenous  saline 
injection,  and  I  should  feel  disposed  to  try  a  saline  solu- 
tion composed  of  O'l  per  cent,  of  sodium  carbonate,  and 
0*5  per  cent,  of  neutral  sodium  phosphate.  When  seen 
at  an  early  stage  before  the  symptoms  are  fully  developed, 
a  vapour  bath  given  in  bed,  and  the  administration  of 
powerful  stimulants  such  as  ether,  ammonia,  musk,  vale- 
rian and  camphor  might  stave  off  the  fatal  attack.  By 
means  of  the  hot  bath,  promptly  administered,  I  believe  I 
rescued  a  patient  from  the  danger  of  a  threatened  attack. 
When  I  saw  her  she  was  drowsy,  her  face  dusky,  her 
breathing  irregular,  the  quantity  of  urine  very  much 
diminished,  and  she  complained  of  severe  abdominal 
pain.  After  the  bath  she  was  much  relieved,  and  went 
on  comfortably  again  for  some  weeks  longer.  When, 
however,  death  is  threatened  by  syncope,  rather  than  by 
coma,  neither  venesection,  nor  the  vapour  bath,  can  be  em- 

GG 


•loO  DISEASES    OF    THE    KIDNEY. 

ployed,  and  we  must  place  our  reliance  entirely  on  stimu- 
lants. As  both  death  by  coma,  and  death  by  syncope, 
may  come  on  at  any  time  during  the  progress  of  a  case  of 
diabetes,  and  as  the  onset  is  usually  sudden,  we  must  be 
on  the  watch,  and  also  instruct  our  patient  to  watch,  for 
threatening  premonitory  symptoms.  Before  the  onset  of 
diabetic  coma,  a  decided  increase  in  the  acidity  of  the 
urine,  or  a  sudden  and  unaccountable  diminution  in  the 
amount  of  urine  and  sugar  excreted,  or  increasing  lividity 
of  the  cheeks  and  lips,  often  give  timely  notice  of  the-  ap- 
proaching danger,  and  give  us  an  opportunity  of  warding 
it  off  for  a  time.  For  this  purpose  alkalies  should  be 
freely  administered  with  the  view  of  diminishing  the 
acidity,  or  to  speak  more  correctly  of  restoring  the  alka- 
lescence of  the  blood  to  its  normal  point ;  whilst  the  eli- 
mination of  any  retained  acid  products,  such  as  oxybutyric 
acid,  a.ceto- acetic  acid  and  the  like,  should  be  promoted  by 
acting  on  the  skin  with  vapour  baths,  and  the  bowels  with 
gentle  purgatives.  The  syncopal  form  of  death  in  dia- 
betes is  generally  preceded  by  symptoms  of  great  exhaus- 
tion and  debility,  for  some  weeks  emaciation  has  been 
more  marked  than  previously,  the  muscles  not  only  have 
wasted  rapidly,  but  are  extremely  soft  and  flaccid,  the 
ansemia  becomes  profound,  whilst  after  any  exertion  slight 
oedema  of  the  lower  extremities  occurs.  From  such  a  state 
of  prostration  it  may  be  possible  to  rescue  the  patient 
by  care  and  attention.  He  should  be  kept  in  bed,  and  his 
diet  carefully  attended  to,  should  his  digestive  powers  fail 
which  is  often  the  case,  and  is  the  cause  of  the  profound 
exhaustion,  it  will  be  necessary  to  give  peptonized  food 
by  the  bowels  in  addition  to  what  can  be  taken  by  the 
stomach.  This  should  be  given  in  as  concentrated  a 
form  as  possible,  raw  meat  rubbed  up  with  cream,  egg 
and  brandy   mixture,   essence   of   beef,  jugged  chicken, 


SUPPRESSION    OF    URINE.  451 

and  the  digestion  of  this  highly  proteid  diet  assisted 
by  means  of  an  acid  sokition  of  pepsin,  taken  after 
each  ingestion  of  food.  Good  brandy  or  dry  port  wine, 
must  be  given  according  to  the  tolerance  of  the  patient 
for  alcohol.  Large  doses,  twenty  to  thirty  drops  of  tinc- 
ture of  perchloride  of  iron,  should  be  given  three  or  four 
times  a  day ;  whilst  a  draught  containing  carbonate  of  am- 
monia, musk,  etc.,  should  always  be  on  readiness  in  case  of 
his  becoming  faint,  or  the  heart's  action  irregular.  Gentle 
massage  will  be  found  useful  in  promoting  the  nutrition 
of  the  muscles,  and  in  restoring  their  lost  tonicity. 


Anuria. 

160.  Suppression  of  Urine. — Heidenhain  {Pflilger's 
Archiv,  vol.  ix.,  1874)  has  made  the  interesting  observa- 
tion, that  after  injecting  a  certain  quantity  of  excre- 
tory material,  and  allowing  such  a  time  to  elapse  as 
he  knew  from  previous  experiments  would  suffice  for 
its  passage  through  the  renal  epithelium  to  be  pretty 
well  completed,  he  found,  if  he  injected  a  second  quan- 
tity, that  "  the  excretion  of  this  second  quantity  was 
most  incomplete  and  imperfect ;  it  seemed  as  if  the 
cells  were  exhausted  by  their  2)revious  efforts,  just  as  a 
muscle  which  has  been  severely  tetanized  will  not  re- 
spond to  a  renewed  stimulation."  That  peculiar  condition 
to  which  Sir  Andrew  Clark  has  given  the  name  "  renal 
inadequacy"  in  which  the  amount  of  urinary  sohds,  and 
often  times  the  quantity  of  urine  itself,  are  considerably 
diminished,  may  probably  originate  from  such  an  ex- 
hausted condition  of  the  epithelium  ;  since  the  disorder 
chiefly  occurs  in  those  who  have  indulged  in  the  pleasures 
of  the  table,  whilst  the  most  satisfactory  treatment  of  the 

gg2 


452  DISEASES    OF    THE    KIDNEY. 

condition,  as  Sir  Andrew  Clark  has  pointed  out,  consists 
in  adopting  a  dietary,  chiefly  of  farinaceous  articles  of 
food.  If  this  is  continued,  the  exhausted  epithelium  seems 
to  recover  itself,  for  after  a  time,  though  the  amount  of 
nitrogen  ingested  is  reduced  to  its  lowest  limit,  the  quan- 
tity of  urea  excreted  begins  again  to  increase. 

In  the  early  stage  of  acute  Bright's  disease,  the  urine 
may  be  completely  suppressed  for  many  hours  or  even  days. 
Three  or  four  days  have  been  recorded.  It  is  a  question, 
however,  whether  the  arrested  or  diminished  flow  of  urine 
in  acute  nephritis,  is  due  to  suppressed  secretion  ;  Prof. 
Hamilton  (op.  cit.)  would  not  be  surprised  if  the  quantity 
of  urine  actually  excreted  by  the  glomeruli  was  increased 
in  these  cases,  but  that  being  unable  to  make  its  way  down 
the  obstructed  tubules  it  is  reabsorbed  ;  and  he  points  out 
the  important  histological  fact  that  the  lymphatic  inter- 
spaces are  all  widened,  both  in  the  glomeruli  and  be- 
tween the  tubules.  On  the  other  hand,  Klein  favours 
the  view  that  the  anuria  in  acute  nephritis,  when  not 
directly  referred  to  inter-tubular  changes,  is  caused  by 
changes  in  the  arterioles ;  and  Klebs  holds  that  the 
suppression  is  due  to  compression  of  the  vessels  of  the 
glomeruli  by  the  pressure  of  the  nuclear  germinations 
(see  p.  195).  Suppression  of  urine  occurs  especially  in 
connection  with  the  acute  nephritis  of  scarlet  fever,  though 
it  may  occur  in  any  of  the  etiological  varieties,  and  may 
arise  as  Dr.  W.  Eoberts  has  pointed  out,  in  scarlet  fever 
dropsy,  unaccompanied  with  albuminuria.  Cases  of  com- 
plete suppression  also  sometimes  occur  in  children  after 
"  cold  catching,"  an  interesting  case  of  which  is  recorded 
by  Dr.  H.  E.  Paxon  {Lancet,  Sept.  29,  1883),  and  others 
have  also  been  recorded.  Indeed,  anything  that  tends  to 
induce  renal  hypersemia  may  lead  to  this  condition.  Thus 
in  poisoning  by   cantharides,  turpentine,   lead,   mineral 


SUPPRESSION    OF    URINE.  453 

acids,  and  other  irritants,  renal  hyper^emia  is  excited,  and 
the  flow  of  urine  suppressed  or  considerably  diminished. 

Mr.  Beck  {ojj.  cit.)  has  insisted  on  the  intimate  nervous 
relation  that  exists  between  the  kidneys,  and  the  urethral 
orifice  of  the  bladder,  trigone,  etc.,  and  believes  that  any 
irritation  of  that  part  is  followed  by  sympathetic  hyperaemia 
of  the  renal  organs.  This  hyperaemia  no  doubt  accounts 
for  the  acute  suppression  of  urine  that  often  follows  after 
the  passage  of  a  catheter,  especially  for  the  first  time,  and 
to  which  Sir  Andrew  Clark  has  drawn  attention  in  his 
paper  read  before  the  Medical  Society  of  London,  1883. 
The  suppression  of  urine  in  these  cases  is  only  temporary, 
for  if  the  patient  recover,  the  secretion  of  urine  again 
goes  on  as  before,  whilst  even  if  fyelo-nephrosis  result, 
neither  the  urine  nor  the  urea  excreted  is  notably  dimin- 
ished, as  has  been  already  stated  (p.  289).  The  suppres- 
sion of  urine,  therefore,  in  these  cases  is  manifestly  due  to 
nervous  influences. 

When  acute  inflammatory  affections,  especially  in  typhus, 
small-pox,  yellow  fever,  and  typhoid  fever,  are  about  to 
terminate  fatally,  the  secretion  of  urine  is  often  suppressed 
for  some  hours  before  death  ;  what  is  known  as  the  "ty- 
phoid state  "  is  a  good  example  of  this  condition.  Care 
must  be  taken,  however,  in  these  cases  not  to  mistake  sup- 
pression of  urine  for  retention  ;  for  urine  may  be  secreted 
by  the  kidney  but  be  retained  in  the  bladder,  owing  to  that 
organ  having  lost  its  extrusive  power. 

The  secretion  of  urine  is  more  or  less  arrested  in  what 
is  known  as  the  state  of  shock  or  collapse.  Thus  it  occurs 
after  severe  injuries  to  the  abdominal  viscera.  The  sup- 
pression of  urine  that  takes  place  in  the  algide  state  of 
cholera  is  due  chiefly  to  the  state  of  collapse,  though  the 
drain  of  water  from  the  system  by  the  bowels,  also  might 
in    some    cases    account   for .  it ;    whilst   if  Dr.    George 


454  DISEASES    OF    THE    KIDNEY. 

Johnson's  theory  is  correct,  of  spasm  of  the  arterioles 
producing  the  collapse,  we  need  seek  no  further  for  an 
explanation  of  the  anuria  of  the  collapsed  stage  of  cholera. 

In  hysterical  females  the  tendency  is  rather  towards  the 
prodigious  discharge  of  large  quantities  of  pallid  urine, 
than  diminution  or  suppression  of  the  secretion,  still  oc- 
casionally it  happens.  In  these  cases,  however,  it  is 
usually  retention  in  the  bladder  and  not  suppressed  secre- 
tion. But  in  a  few  rare  cases  true  suppression  does  oc- 
cur. I  had  a  case  of  this  kind  once  under  observation 
in  the  Doncaster  Workhouse,  the  girl  aged  nineteen  used 
to  get  trance-like  seizures,  often  lasting  two  or  three  days, 
during  which  time,  very  little,  and  on  some  occasions,  no 
urine  as  far  as  could  be  ascertained,  would  be  secreted ; 
during  the  continuance  of  the  attack,  she  used  to  be 
troubled  with  hiccough  and  occasionally  vomited.  I  regret 
now  that  I  did  not  examine  the  vomit  to  see  if  it  contained 
urea,  it  certainly  had  not  a  urinous  odour,  nor  was  it  pro- 
fuse. These  attacks  used  to  come  on  two  or  three  times 
a  year,  but  occasionally  the  hysterical  manifestations 
would  take  other  forms. 

The  treatment  of  suppression  of  urine  must  generally 
be  conducted  on  the  principles  indicated  for  its  manage- 
ment when  it  occurs  in  acute  nephritis  (see  p.  252).  When 
due  to  shock,  and  there  is  no  reason  to  suspect  that  the 
kidneys  are  diseased,  opium  should  be  administered.  In 
the  suppression  of  urine  in  cholera,  the  means  taken  to 
restore  the  patient  from  his  collapsed  condition  will,  if  suc- 
cessful, be  followed  by  restoration  of  the  secretion,  the 
first  samples  passed  being  bloody  and  highly  albuminous. 
Hysterical  suppression  is  best  disregarded,  as  far  as  our 
conduct  towards  the  patient  is  concerned ;  the  adminis- 
tration, however,  of  valerian,  valerianate  of  zinc,  bromide 
of  potassium  may  help  us  to  overcome  more  speedily  the 


RETENTION    OF    URINE.  455 

neurotic  element  in  the  affection.  If  troublesome  vomit- 
ing should  arise  during  suppression,  from  any  cause,  it  is 
best  combated  by  the  administration  of  drop  doses  of 
hydrocyanic  acid  in  a  teaspoonful  of  water,  mustard  plas- 
ters to  the  epigastrium,  and  injections  of  chloral  hydrate 
by  the  rectum. 

.  161.  Retention  of  urine  may  be  conveniently  con- 
sidered here,  though  it  cannot  be  regarded  in  any  way  as 
a  functional  derangement,  but  merely  as  a  symptom  of 
some  mechanical  impediment  to  the  discharge  of  urine 
already  secreted.  Obstruction  to  the  flow  of  urine  may 
occur  at  any  point  of  the  urinary  tract ;  in  the  urethra, 
from  stricture,  vascular  growths,  or  pressure  from  a  peri- 
neal abscess  ;  at  the  neck  of  the  bladder,  from  an  en- 
larged prostate ;  in  the  bladder,  from  abnormal  growths 
obstructing  the  orifice  of  the  ureters  ;  or  the  bladder  may 
be  compressed  by  a  tumour  from  without,  as  occurred  in 
a  case  at  the  Seamen's  Hospital,  in  which  a  cystic  growth 
of  the  right  vesicula  seminaUs  increased  to  such  a  size, 
that  making  its  way  upwards  between  the  bladder  and 
rectum,  it  compressed  and  flattened  the  bladder,  and  com- 
pletely obstructed  the  lower  portion  of  both  ureters,  caus- 
ing during  the  last  few  days  of  life  complete  retention. 
Or  the  ureters  may  be  occluded,  by  stricture,  by  the  im- 
X3action  of  calculi ;  or  obstructed  by  cancerous  or  tuber- 
cular masses,  or  by  blood  clots ;  or  by  the  formation  of 
valvular  folds,  or  thickened  condition  of  the  mucous  mem- 
brane ;  or  compressed  by  tumours  from  without. 

The  retention  may  be  complete  or  partial.  When  the 
former  is  the  case,  the  obstruction  is  situated  either  in  the 
urethra,  or  at  the  neck  of  the  bladder,  or  both  ureters  are 
compressed,  or  else  the  patient  has  only  one  kidney  avail- 
able for  secretion,  the  other  being  congenitally  absent  or 
destroyed  by  previous   disease.      When  the  retention  is 


456  DISEASES    OF    THE    KIDNEY. 

partial,  then  either  the  obstruction  does  not  absohitely 
impede  the  flow  of  urine  as  is  the  case  with  many  stric- 
tures of  the  urethra,  or  else  it  is  so  situated,  as  when  only 
one  ureter  is  obstructed,  as  to  allow  the  discharge  of  urine 
by  the  unaffected  channel. 

Ketention  may  be  produced  suddenly,  as  when  for  in- 
stance a  renal  calculus  suddenly  obstructs  the  ureter  in  a 
patient,  who  has  only  one  kidney  that  secretes  urine. 
Thus  in  the  case  of  a  sailor  admitted  into  the  Seamen's 
Hospital  with  suppression  of  urine,  and  who  the  previous 
day  had  received  a  severe  blow  across  the  loins,  it  was 
found,  post-mortem,  that  the  left  kidney  was  absolutely 
destroyed  by  the  pressure  of  a  large  branched  calculus, 
whilst  the  right  was  fauiy  healthy,  but  in  the  upper  part 
of  whose  ureter  was  found  impacted  a  small  calculus. 
This  had  been  dislodged  by  the  blow,  from  its  position  in 
the  iDelvis  of  the  kidney,  and  had  entered  the  ureter,  but 
being  unable  to  pass  had  caused  the  fatal  obstruction. 
In  the  majority  of  cases,  however,  the  onset  of  retention 
is  gradual,  there  may  be  some  difficulty  in  passing  water, 
but  a  little  more  extrusive  force  overcomes  the  resistance, 
as  is  often  seen  in  cases  of  stricture  of  the  urethra.  Or 
the  bladder  may  become  distended,  and  instead  of  the 
urine  coming  in  a  full  stream  it  dribbles  away,  as  in  en- 
larged prostate,  or  in  paraplegia.  Or  the  urine  accumu- 
lates behind  the  obstacle,  till  at  length  the  vis  a  tergo  is 
sufficient  to  overcome  the  resistance,  and  the  accumulated 
urine  is  discharged ;  this  occurs  chiefly  in  those  cases  in 
which  the  obstruction  is  seated  in  the  ureter.  Here  we 
have  periods  of  complete  retention  alternating  with  a  dis- 
charge of  somewhat  aqueous  urine  (see  also  hydro-nephro- 
sis,  p.  319). 

The  effects  of  long- continued  obstruction  are  observable 
in  the  dilated  and  distended  con,ditiou  of  the  urinary  pas- 


EETENTION    OF   XJEIXE. 


457 


sages  behind  the  obstruction.  Eupture  does  not,  however, 
occur,  because  when  the  pressure  in  the  distended  urinary 
passages  rises  to  the  degree  of  the  blood  pressure  in  the 
renal  vessels,  the  further  secretion  of  urine  is  arrested,  so 
that  long-continued  retention  leads  at  last  to  suppression 
of  urinary  secretion.  When,  however,  the  obstruction 
is  long-continued,  the  distension  leads  to  considerable 
changes  in  the  urinary  organs.  The  walls  of  the  ureters 
become  thickened,  both  from  hypertrophy  of  the  muscular 
wall  and  from  swelling  of  the  mucous  membrane,  whilst  the 
cavity  is  dilated  so  as  to  resemble  a  piece  of  small  intes- 
tine ;  the  pelvis  of  the  kidney  becomes  distended  and  its 
calices  dilated  ;  then  commences  absorption  of  the  i)yra- 
midal  portion  of  the  kidney  commencing  at  the  papillae. 
The  whole  of  the  pyramidal  portion  may  eventually  dis- 
appear leaving  only  hollow  depressions  formed  by  ex- 
panded calyces.  Finally,  the  cortex  dwindles,  and  be- 
comes stretched  and  thinned,  and  the  kidney  becomes 
converted  into  a  cyst  (see  also  pyo-nephrosis,  p.  278,  and 
hydro-nephrosis,  p.  320),  This  absorption  of  the  renal 
tissue  would  proceed  more  rapidly  were  it  not  accom- 
panied by  chronic  interstitial  nephritis,  which  causes  an 
overgrowth  of  the  connective  tissue.  This  overgrowth, 
as  Beck  {oj).  cit.)  has  pointed  out,  may  be  regarded  as 
mainly  conservative,  rendering  the  kidney  more  capable 
of  withstanding  the  stretching  to  which  it  is  exposed. 
Again,  as  we  have  seen,  when  the  pressure  in  the  urinary 
passages  equals  the  pressure  in  the  renal  vessels,  secre- 
tion of  urine  is  arrested.  Now  the  effect  of  this  growth 
of  connective  tissue,  as  Beck  observes,  prevents  this  set- 
ting in  at  an  early  period,  for  the  new  growth  between  the 
tubules  causes  some  degree  of  obsti'uction  to  the  venous 
circulation  and  so  increases  the  pressure  in  the  Malpighian 
tufts.     The  result  being,  so  far  fi'om  secretion  being  di- 


458  DISEASES    OF    THE    KIDNEY. 

minislied,  it  is  increased,  especially  as  regards  tlie  amount 
of  water,  and  thus  for  a  time  suppression  of  urine  is 
averted. 

Complete  retention  ends,  as  already  stated,  ultimately 
in  suppression  of  the  secretion  of  urine.  The  period  that 
intervenes  between  the  commencement  of  the  retention  and 
the  fatal  termination  varies  considerably,  and  depends  very 
much  on  the  nature  of  the  obstruction  and  state  of  the  urin- 
ary passages.  When  these  are  healthy,  and  the  obstruction 
sudden,  as  for  instance,  when  a  calculus  blocks  the  ureter 
of  a  sohtary  kidney,  the  patient  may  survive  several  days, 
as  many  as  twenty- one  days  have  been  recorded  [Trans. 
Clin.  Soc,  vol.  ii.).  In  cases,  however,  in  which  the  obstruc- 
tion is  brought  about  by  previous  disease  of  the  urinary  pas- 
sages, and  there  has  been  long-standing  pyelitis  or  cystitis, 
a  fatal  termination  will  probably  occur  much  earlier,  owing 
to  the  supervention  of  suppurative  nephritis,  though  even 
in  these  cases  the  patient  may  survive  even  five  or  six 
days.  The  fatal  termination  is  ushered  in  by  ursemic 
sym^jtoms,  though  these  are  not  generally  of  a  violent 
character,  convulsions  and  coma  being  rare,  muscular 
twitchings  and  a  heavy  di-eamy  state  being  the  main  fea- 
tures. The  pupils  are  often  contracted,  the  tongue  dry 
and  brown,  the  temperature,  when  the  urgemic  state  is 
pronounced,  often  becomes  subnormal.  Vomiting  and 
diarrhoea  sometimes  occur,  and  are  usually  provoked 
rather  than  spontaneous  ;  but  hiccough  is  common.  The 
skin  is  moist,  sometimes  drenched  with  cold  sweat. 

"When  the  retention  is  partial,  as  for  instance  in  the  case 
of  enlarged  prostate,  the  case  may  run  a  protracted  course 
before  the  ultimate  destruction  of  all  renal  secretion  tis- 
sue by  pressure.  Owing  to  the  increased  i^ressure  in  the 
Malpighian  vessels  by  the  obstruction  caused  by  the 
growth   of  the   connective   tissue,   the   amount   of  urine 


RETENTION    OF    URINE.  459 

secreted  is  increased,  though  it  is  deficient  in  soHd  matter. 
When  the  retention  affects  one  kidney  only,  and  the  other 
remains  healthy,  the  sound  organ  in  time  takes  on  the 
work  of  the  one  whose  function  is  suppressed,  and  no 
further  ill  consequences  may  result. 

The  treatment  of  retention  of  urine  is  mainly  a  surgical 
question.  When  the  obstruction  is  due  to  impaction  of  a 
calculus  in  the  urinary  passages,  we  may  endeavour  to 
promote  its  onward  passage  by  the  means  suggested  in 
the  ensuing  chapter,  but  should  it  obstinately  resist  our 
efforts  the  propriety  of  surgical  interference  must  be  dis- 
cussed. This  becomes  imperative,  if  from  the  fact  of  the 
urinary  secretion  being  entirely  arrested,  we  are  lead  to 
the  conclusion  that  the  kidney  obstructed  was  the  only 
one  available  for  use,  and  that  the  other  is  either  congeni- 
tally  absent,  or  else  incapacitated  by  previous  disease. 
Happily  owing  to  the  advances  of  renal  surgery,  operative 
procedures  are  attended  with  abundant  success  in  a  large 
proportion  of  these  cases.  When  the  obstruction  occurs 
in  the  lower  urinary  passages  from  stricture  or  enlarged 
prostate,  no  time  should  be  lost  in  affording  instrumental 
relief,  before  hypertrophy  of  the  muscular  walls  of  the  blad- 
der occurs,  and  thus  prevents  compression  of  the  orifices 
of  the  ureters  by  the  thickened  muscular  bundles.  This 
cannot  be  too  much  insisted  on,  since  I  fear  it  is  too  often 
the  practice  to  defer  catheterism,  so  long  as  the  patient 
can  pass  urine  without  apparent  difficulty.  For  a  similar 
reason  vesical  calculus  should  be  removed  as  soon  as 
detected,  and  cystitis  treated  with  vigour. 


460  DISEASES    OF    THE    KIDNEY. 


CHAPTEK  X. 

Stone  and  Gravel. 

162.  Origin  of  Stone. — The  older  writers  distinguished 
between  gravel  and  urinary  deposits,  by  the  fact  that  the 
former  was  separated  Irom  the  urine  in  the  urinary 
passages  and  discharged  with  the  urine,  whilst  the  latter 
was  only  deposited  after  the  urine  had  left  the  bladder. 
If  gravel  were  retained  in  the  urinary  passages,  and  it  be- 
came concreted,  then  a  stone  was  formed.  This  concretion 
according  to  their  view  might  take  place,  either  in  con- 
sequence of  the  heat  and  dryness  of  the  urinary  organs 
drying  the  slime,  just  as  a  portion  of  soft  clay  may  by 
external  heat  be  turned  into  brick  or  tile  (Hippocrates),  in 
which  case  the  calculus  would  be  reddish  ;  or  by  coldness 
or  humidity  of  the  parts,  as  marble  is  formed  (M.  Sanctus), 
when  the  calculus  would  be  of  a  whitish  colour.  These 
speculations  of  the  ancient  physicians  point  to  an  en- 
tirely local  origin  for  stone.  The  chemical  doctrines  of 
Paracelsus,  Van  Helmont,  and  the  iatro- chemists  of  the 
sixteenth  and  seventeenth  centuries  threw  this  view  into 
the  background.  Calculous  matter,  according  to  Paracelsus, 
was  of  the  nature  of  tartar,  and  caused  by  the  union  of  a 
nutritive  principle  with  a  saline  spirit,  which  coagulated 
the  earthy  matter  of  the  urine.  We  have  here  the  first 
indication  of  the  chemical  origin  of  stone,  and  in  the  doc- 
trine of  the  archceus  a  foreshadowing  of  the  idea  of  con- 
stitutional diatheses,  which  for  many  years  dominated 
urinary  pathology.  "When,  however,  the  iatro-chemical 
school  fell  into  discredit,  physicians  reverted  to  the  old 


STONE    AND    GRAVEL.  461 

views,  and  stone  once  more  was  considered  as  of  local 
origin,  as  was  ably  set  forth  by  Dr,  Austin  in  the  Gul- 
stonian  Lecture  of  1790.  But  a  new  school  of  chemistry 
was  arising,  based  upon  actual  analytical  fact  and  not 
hypothesis.  In  1776,  Scheele  discovered  uric  acid,  which 
from  being  found  in  the  majority  of  calculi  was  termed 
lithic  acid,  whilst  the  discovery  of  calcium  oxalate, 
ammonio-magnesium  phosphate  and  calcium  phosphate, 
as  constituents  of  some  stones,  was  made  soon  after.  It 
was  first  supposed  that  these  substances  were  formed  in 
the  body,  and  eliminated  in  such  quantities  as  to  be  precipi- 
tated in  the  urinary  passages,  where  by  their  aggregation 
they  formed  a  stone,  and  hence  the  application  of  the  doc- 
trine of  "  diatheses  "  to  urinary  pathology.  The  next  ad- 
vance, however,  was  to  show  that  excessive  production  and 
elimination  was  not  essential  for  the  formation  of  calculus, 
and  that  alterations  in  the  reaction  of  the  urine  was  an  im- 
portant element  to  be  taken  into  account,  since  many  of  the 
substances  entering  into  the  composition  of  a  stone,  when 
present  only  in  their  normal  proportions,  may  be  precipi- 
tated when  there  is  a  marked  change  in  the  reaction  of  the 
urine.  Still,  however,  the  formation  of  stone  could  not  be 
satisfactorily  attributed  altogether  to  these  chemical  varia  - 
tions  in  the  composition  of  the  urine,  since  undoubtedly 
urinary  matters  were  frequently  precipitated  without  its 
occurrence.  At  this  point  the  important  researches  of 
Eainey  on  molecular  coalescence,  again  drew  attention  to 
the  part  played  by  local  conditions  in  the  formation  of 
stone,  by  indicating  that  the  mucus  of  the  urinary  pas- 
sages furnished  the  medium  requisite  for  the  aggregation 
of  the  precipitated  urinary  matters.  Professor  Kainey's 
observations  have  been  followed  up  by  Vandyke  Carter  (079. 
cit.)  and  Ord  (op.  cit.),  and  it  has  been  clearly  demon- 
strated that  in  the  presence  of  a  suitable  coUoid  medium, 


462  DISEASES    OF    THE    KIDNEY. 

precipitated  urinary  matters  lose  their  crystalline  form 
and  become  sub-morphous,  that  is  become  more  or  less 
spheroidal.  The  nature  of  this  colloid  medium  is,  how- 
ever, at  present  not  determined.  It  can  hardly  be  the 
ordinary  mucus  furnished  by  the  urinary  passages  under 
catarrhal  and  inflammatory  conditions,  since  if  that  were 
the  case,  calculous  formations  would  be  infinitely  more 
common  than  they  are,  though  no  doubt  when  stone  is 
once  originated  both  renal  and  vesical  catarrh  furnishes 
the  medium  for  its  increase  in  growth.  In  order  to  over- 
come this  difficulty  many  have  suggested  the  existence  of 
some  special  form  of  mucus  as  furnishing  the  colloid 
medium.  Thus,  the  Germans  speak  of  a  stone-forming 
catarrh  (stein  bildenden  catarrh),  in  which  the  mucus 
undergoing  acid  fermentation  leads  to  the  precipitation  of 
uric  acid,  or  the  formation  of  oxalate  of  lime.  Dr.  Owen 
Eees  {op.  cit.)  thinks  that  in  gout  the  urinary  passages 
furnish  a  mucus  secretion,  which  has  a  special  tendency 
to  agglutinate  and  form  masses.  Whilst  others  have 
imagined  that  stone  is  the  result  of  some  chronic  inflam- 
matory condition. 

In  considering,  however,  the  origin  of  stone,  the  question 
must  be  separated  from  that  which  concerns  its  growth.  All 
stones  present  a  point  round  which  all  subsequent  depo- 
sition collects,  and  it  is  to  the  study  of  this  central  nucleus 
that  our  attention  must  be  directed  if  we  wish  to  trace  the 
early  history  of  calculous  formations.  Now  the  nuclei  of 
all  urinary  calcuH,  except  in  the  case  of  foreign  bodies 
introduced  from  without,  have  a  renal  origin,  that  is  they 
are  not  formed  in  the  pelvis  of  the  kidney,  but  in  the 
urinary  tubules.  This  is  not  a  mere  supposition,  but  is 
supported  by  pathological  evidence.  For  instance,  in  the 
small  pisiform  calculi  (of  uric  acid)  so  common  in  elderly 
people,  we  sometimes  have  an  opportunity  of  seeing,  post- 


STONE    AND    GRAVEL. 


463 


mortem,  a  minute  calculus  separating  from  the  mammillary 
processes.  An  instance  of  this  kind  has  been  described 
by  Sir  Benjamin  Brodie,  in  his  Lectures  on  Diseases  of 
the  Urinary  Organs,  in  which  the  mammillary  pro- 
cesses having  been  longitudinally  divided,  the  tubuli 
uriniferi  were  seen  blocked  up  with  calculous  matter  ;  in 
one  of  them  the  development  of  the  calculus  being  further 
advanced  it  was  seen  partly  embedded  in  the  apex  of  the 
mammillary  process,  and  partly  projecting  into  the  in- 
fundibulum.  The  uric  acid  infarcts  that  occur  .in  young 
infants  is  another  evidence  of  the  deposit  of  calculous 
matter  in  a  sub-morphous  form  in  tubules  of  the  kidney. 
Those  who  admit  the  early  formation  of  calculi  in  the 
straight  portion  of  the  renal  tubule,  account  for  it  by  the 
fact  that  the  urine  is  more  concentrated  in  this  portion  of 
the  .tubule  ;  but  as  I  have  pointed  out  {Gliyiical  Chemistry, 
p.  239),  the  degree  of  concentration  is  sUght,  whilst  the 
diameter  of  the  straight  portion  of  the  tubule  being  wider 
than  the  convoluted,  the  flow  of  urine  through  it  is  freer, 
which  compensates  for  any  degree  of  concentration  that 
occurs.  Moreover,  concentration  of  urine  whilst  account- 
ing for  crystalline  deposition  does  not  account  for  the 
formation  of  sub-morphous  bodies,  such  as  compose  this 
calculous  material.  It  may  happen  that  the  colloid  material 
is  furnished  by  some  special  secretion  of  the  renal  cells, 
but  of  this  we  have  no  positive  evidence.  Whilst  thinking 
over  this  matter  a  few  years  ago,  I  came  across  in  Dr. 
Golding  Bird's  work  on  Urinary  Deposits,  a  representation 
of  a  renal  cell  filled  with  octahedral  crystals  of  oxalate  of 
lime,  and  which  had  been  detected  in  the  urine  by  Dr.  G. 
Johnson.  Further,  on  referring  to  some  lectures  of  Pro- 
fessor Quekett  {Medical  Tiynes  and  Gazette),  I  learnt  that  in 
those  animals  who  secrete  uric  acid  in  large  quantities  from 
the  kidneys,  this  substance  is  often  contained  in  the  cells 


464  DISEASES    OF    THE    KIDNEY. 

of  the  renal  epithelium.     It  therefore  appeared  to  me  that 
the  deposition  of  calculous  matter  forming  the  original  nu- 
cleus, might  also  in  man  occur  primarily  in  the  cells  form- 
ing the  wall  of  the  renal  tubules,  and  not  in  the  lumen  of 
the  tube  itself,  and  further  that  this  deposition  was  caused 
by  some  vital  imjjairment,  so  that  products  that  normally 
ought  to  be  eliminated  by  the  renal  cells  are  retained  and 
deposited  by  them  instead.     Many  arguments  may  be  ad- 
duced in  support  of  this  view.     Heidenhain's  experiments 
(p.  451)  have  shown  that  with  regard  to  one  substance  at 
least,  the  renal  epithelium  does  exercise  a  distinct  secreting 
activity,  independent  of  and  distinct  from  the  relations  of 
blood  pressure,  nay  more,  he  has  shown  that  the  renal 
cells  may  even  become  exhausted  by  their  previous  efforts  at 
ehmination  (Foster's  Physiology).      Again,  the  part  of  the 
urinary  tubules  in  which  calculous  deposits  are  most  fre- 
quent is  the  straight  portion,  especially  the  lower  part 
towards    the   mammillary  processes.      This    as   is   well 
known  is  less  freely  supplied  with  blood  than  any  other 
part  of  the  kidney  tubule,  and  we  know  by  analogy,  that 
textures   possessed   of  a  feeble  cu'culation  are  prone  to 
degenerative  changes,  especially  to  deposits  of  this  kind,  as 
witness  the  tophi  in  the  cartilages  of  the  joints  and  ears  in 
gout.     Besides  this,  the  basement  membrane  is  absent  at 
this  part  of  the  tubule,  so  that  the  wall  consists  alone  of 
epithelium,  this  probably  has  some  determining  influence. 
Another  point  which  I  think  also  may  fairly  be  taken  into 
consideration  in  support  of  the  view  that  calculous  deposit 
occurs  in  the  renal  cells  as  the  result  of  their  vital  im- 
pairment, is  the  fact  that  stone  is  most  frequent  at  the 
extreme  periods  of  life,  viz.,  during  childhood  and  old  age, 
when  either  from  rapidity  of  growth,  or  general  decay,  the 
vital  powers  undergo  impairment.      Stone,  moreover,  not 
infrequently  occurs   after  disorders   which   have   greatly 


STONE    AND    GRAVEL.  465 

exhausted  the  vital  powers,  and  this  probably  explains  the 
frequent  association  of  stone  with  gout,  since  in  that  dis- 
ease there  is  always  more  or  less  a  condition  of  impaired 
vitality  and  textural  degeneration.  Lastly,  if  Heidenhain 
is  correct  in  saying  that  the  renal  cells  become  exhausted 
by  oyer  activity,  the  constant  over  eUmination  of  uric 
acid,  oxalic  acid,  etc.,  might  lead  to  their  deposit  in  the 
renal  cells,  owing  to  the  impairment  of  the  activity  of  the 
epithelium.  The  sudden  onset,  too,  of  renal  colic,  is  in  favour 
of  the  view  of  the  tubular  origin  of  renal  calculi,  since  if 
the  nucleus  was  moulded  in  the  pelvis  of  the  kidney,  and 
gradually  developed,  the  onset  of  the  symptoms  would  be 
gradual,  whereas  colic  generally  sets  in  without  warning, 
as  if  a  foreign  body  had  suddenly  dropped  into  the  pelvis 
of  the  kidney.  The  only  objections  that  can  be  raised  to 
the  cellular  origin  of  the  nuclei  of  calculi,  lies  in  the  fact 
that  no  remnants  of  a  cell  wall  can  be  found  in  examining 
the  formed  nuclei.  But  reflection  must  convince  us  that 
the  observation  of  a  cell  wall,  like  that  depicted  by  Golding 
Bird  and  seen  by  Dr.  Gr.  Johnson,  must  be  of  extremely 
rare  occurrence,  and  only  possible  in  the  very  earliest 
stage  of  formation,  since  the  cell  wall  furnishing  the  colloid 
medium,  must  itself  be  incorporated  with  the  crystalline 
bodies  to  form  the  sub-morphous  granules  that  compose 
the  calculous  material.  In  thus  claiming  for  the  nuclei  of 
calculi  a  cellular  origin,  I  of  course  exclude  those  in  which 
the  nucleus  is  distinctly  hsemic,  as  may  occur  after  blows 
and  injuries  to  the  kidney,  or  are  mere  collections  of 
altered  fatty  matters,  as  in  concretions  of  uro-steahth. 

To  sum  up,  therefore,  the  views  I  think  we  may  hold 
with  regard  to  the  origin  of  stone,  I  would  say : — 

1.  That  all  urinary  calculi,  except  those  formed  upon 
extraneous  substances  introduced  into  the  bladder,  have  a 
renal  origin. 

HH 


466 


DISEASES    OF    THE    KIDNEY. 


2.  That  the  nuclei  of  all  renal  calculi,  except  those  of 
evidently  hsemic  origin,  are  developed  in  the  tubules  of  the 
kidney. 

3.  That  these  nuclei  probably  take  their  origin  in  the 
renal  cells,  by  the  retention  within  them  of  uric  acid,  oxalate 
of  lime  or  phosphate  of  lime,  owing  to  some  vital  impair- 
ment of  their  function,  by  which  their  power  of  eliminating 
these  substances  is  diminished. 

4.  That  the  nucleus,  having  passed  into  the  urinary 
passages,  grows  by  a  gradual  accretion  in  successive  layers 
to  its  surface,  the  material  for  which  is  furnished  by  the 
mucus  of  these  passages,  and  the  substances  deposited 
from  the  urine. 

5.  That  the  nature  of  the  successive  layers  of  a  fully 
formed  calculus,  will  be  found  to  vary  according  to  the 
prevaihng  character  of  the  urine  at  the  time  of  their  for- 
mation, so  that  in  the  same  calculus  we  may  find  layers  of 
uric  acid  alternating  with  phosphate  of  lime,  and  finally 
incrusted  with  a  coat  of  triple  phosphate,  or  any  other 
possible  variation. 


Varieties  of  Ueinary  Gravel  and  Concretions. 

163.  Iiithuria. — Uric,  or  lithic,  acid,  as  it  is  generally 
called,  from  the  old  idea  that  it  was  the  essential  constitu- 
ent of  stone,  is  deposited  from  the  urine  either  in  a  free 
state,  or  combined  with  bases  as  salts,  whenever  the 
urine  is  highly  acid,  or  when  uric  acid  is  either  absolutely 
or  relatively  in  excess.  Considerable  difference  of  opinion 
exists  as  to  the  mode  of  formation  of  uric  acid  within  the 
human  body,  and  its  pathology.  According  to  the  gener- 
ally received  opinion,  uric  acid  is  one  of  those  substances, 
through  which  every  particle  of  proteid  matter  passes,  be- 


LITHUEIA.  467 

fore  it  is  thrown  out  of  the  body,  and  therefore  when  oxi- 
dation is  imperfectly  performed  in  the  organism,  uric  acid 
and  the  urates  are  not  reduced  to  the  form  of  soluble  urea. 
The  conditions  that  bring  about  this  condition  of  imperfect 
oxidation  are  numerous,  and  may  be  referred  to  disturb- 
ance of  the  nitrogenous  equilibrium,  the  employment  of 
too  highly  animalized  a  diet,  by  nervous  influences,  or  the 
disturbance  of  function  of  some  important  organ  (the  liver 
according  to  most  authorities).  There  are  difficulties, 
however,  in  the  way  of  accepting  this  as  a  complete  ex- 
planation. In  the  first  place,  uric  acid  is  only  found  in 
very  small  quantities  in  the  human  body,  and  then,  except 
in  gout,  is  only  found  in  the  tissues  and  never  in  the 
blood.  Again,  it  has  been  shown  that  uric  acid  is  not  a 
necessary  antecedent  of  urea,  and  that  it  is  more  proba- 
ble that  the  antecedents  of  urea  in  the  blood  are  ]Dartly 
kreatin  and.  partly  leucin.  Again,  after  strictly  non- 
nitrogenous  diet,  uric  acid  is  always  found  in  the  urine, 
and  this  in  spite  of  the  fact  that  the  nitrogen  is  cut  off, 
and  consequently  the  oxygen  is  in  relative  excess ;  surely  if 
the  hypothesis  above  mentioned  were  correct,  all  the  uric 
acid  ought  to  have  been  converted  into  urea,  but  it  is  not 
so,  but  passes  off  pari  imssuy^iih.  the  urea,  as  if  furnished  by 
special  cells  (P.arkes) .  Moreover  it  has  been  pointed  out  that 
the  amount  of  uric  acid  excreted  daily  is  within  narrow 
limits  comparatively  constant,  and  the  want  of  connexion 
between  its  changes  and  the  variations  in  the  amount  of 
urea  in  health  and  disease,  also  seems  to  afford  strong 
arguments  against  the  supposition,  that  urea  is  largely 
derived  from  uric  acid.  These  objections  and  others, 
which  might  also  be  advanced,  have  somewhat  discredited 
the  "imperfect  oxidation  theory,"  and  fresh  views  and 
hypotheses  are  already  being  advanced.  Professor 
Latham  of  Cambridge  {p'p.  cit.)  believes  that  the  abnormal 

hh2 


468  DISEASES    OF    THE    KIDNEY. 

formation  of  uric  acid  in  the  human  body,  occurs  just  as  in 
the  case  of  glucose  in  diabetes,  on  the  inabihty  of  the 
hver,  or  system  generally,  to  effect  the  metabolism  of 
glycocine.  This  glycocine,  derived  from  the  glycocholic 
acid  of  the  bile,  after  the  bile  has  served  its  purpose  in 
digestion,  is  conveyed  to  the  liver  and  is  converted,  not 
into  urea  as  we  would  naturally  expect,  but  into  an  amido- 
body,  to  which  Dr.  Latham  gives  the  hypothetic  formula 

coj^s-co 

JNH       1 
^^  {  NH— CHa  ■ 

and  which  passes  from  the  liver  into  the  circulation,  and 
when  it  reaches  the  kidney  is  converted  by  conjugation 
with  urea  into  ammonium  urate,  thus  : — 

Urea.  Amido-body.  Ammonium  urate. 

CO    Sw   +         >  NH       1       =  H,0  +  C^HsN.Oe,  NH, 


INH,       ^0 


{  NH— CH2 


Uric  acid  according  to  this  view  depends  upon  a  func- 
tional derangement  of  the  liver  in  regard  to  the  metabolism 
of  glycocine,  and  Dr.  Latham  therefore  advises  that  treat- 
ment be  directed,  first  of  all,  to  measures  by  which  the 
formation  of  glycocine  can  be  lessened,  such  as  by  proper 
diet,  which  should  be  chiefly  farinaceous  with  ihe  avoid- 
ance of  all  gelatinous  articles.  Also  that  the  amount  of 
glycocine  be  lessened  in  the  system  by  exercise,  and  by  the 
use  of  saline  cathartics.  Secondly,  remedies  are  to  be 
administered  which  will  combine  with  glycocine,  and  so 
prevent  the  formation  of  uric  acid,  such  as  benzoic  acid, 
which  according  to  his  view  and  that  of  Dr.  Garrod,  passes 
out  of  the  system  conjugated  with  glycocine  as  hippuric 


LITHURIA.  469 

acid.  Iodide  of  potassium  and  chloride  of  ammonium"  are 
other  remedies,  which,  Dr.  Latham  thinks,  act  by  prevent- 
ing the  conjugation  of  glyeocine  with  urea  to  form  uric 
acid,  since  hydriodic  acid  and  hydrochloric  acid  both,  out 
of  the  body,  decompose  uric  acid,  hence  as  he  suggests, 
the  beneficial  effect,  that  certain  mineral  waters,  rich  in 
chlorides,  have  on  gouty  patients.  Before  Dr.  Latham's 
view  can  be  accepted,  there  are  several  points  connected 
with  it  that  require  further  explanation  and  discussion. 
His  hypothesis  for  instance  tells  us  how  ammonium  urate 
may  be  formed,  but  it  does  not  explain  how  it  is  that 
sodium  urate  is  the  salt  deposited  in  the  tissues,  unless 
we  have  recourse  to  a  theory  of  double  decomposition. 
Again,  uric  acid  of  all  urinary  constituents  is  the  one  least 
affected  by  variations  of  diet,  yet  still  we  should  expect,  if 
the  glyeocine  theory  were  true,  that  excessive  ingestion  of 
this  substance,  or  food  rich  with  it,  would  lead  to  an  in- 
crease of  uric  acid  in  the  urine,  but  is  this  the  case  ? 
Moreover,  if  iodide  of  potassium  prevents  the  conjugation 
of  glyeocine  with  urea,  would  not  there  be,  if  Dr.  Latham's 
hypothesis  were  correct,  a  diminution  of  uric  acid  in  the 
urine  when  this  drug  is  administered,  whereas  according 
to  most  authorities,  iodide  of  potassium  increases  the 
elimination  of  uric  acid.  Moreover,  Dr.  Cook  [Brit.  Med. 
Jour.,  July,  1883)  has  shown  that  so  far  from  benzoic 
acid  and  the  benzoates  diminishing  the  amount  of  uric 
acid,  by  replacing  the  conjugation  of  glyeocine  with  urea, 
for  a  conjugation  with  benzoic  acid,  leading  to  the  forma- 
tion of  hippuric  acid,  the  formation  of  uric  acid  is  not 
checked  by  the  administration  of  these  substances,  but 
that  they  merely  prevent  uric  acid  from  crystallizing  out 
from  solutions,  and  thus  being  presented  in  a  ponderable 
form.  Without  accepting  any  special  theory  with  regard  to 
the  formation  of  uric  acid  the  following  propositions  may  be 
offered  as  being  most  in  accordance  with  ascertained  facts. 


470  DISEASES    OF    THE    KIDNEY. 

1.  That  uric  acid  is  only  fotind  to  a  slight  extent  in  the 
human  body.  2.  That  in  health  it  is  probably  destroyed 
at  the  seat  of  its  formation,  viz.,  in  the  tissues  or  organs, 
since  uric  acid  cannot  be  obtained  from  healthy  blood  in 
quantities  sufficient  for  identification.  3.  In  gout  alone  does 
uric  acid  appear  in  the  blood.  4.  The  cause  of  this  ap- 
pearance in  the  blood  may  be  due  (a)  to  excessive  produc- 
tion, and  that  a  portion  so  produced  is  not  destroyed  in 
the  tissues  and  organs  ;  (b)  that  owing  to  some  failure  of 
oxidation  probably  from  disturbance  of  innervation  acting 
through  the  vaso-motor  nerves,  the  uric  acid  is  not  de- 
stroyed in  the  tissues  or  organs.  5.  If  the  first  supposition 
(a.)  is  accepted  then  we  must  suppose  that  the  uric  acid  is 
carried  by  the  blood  current,  and  deposited  in  regions 
where  the  cu'culation  is  feeble,  as  in  the  cartilages  of  the 
joints  and  ears,  or  in  the  straight  portions  of  the  urinary 
tubules  (p.  231).  If  the  second  hypothesis  (6)  is  held,  then 
an  explanation  must  be  sought  in  the  supposition,  that  the 
uric  acid  not  destroyed  is,  in  the  case  of  the  large  organs, 
swept  into  the  circulation  where  it  gradually  becomes  oxi- 
dized, but  in  the  case  of  the  tissues  where  the  circulation 
is  feeble  as  in  the  cartilages  of  the  joints,  etc.,  it  is  simply 
deposited.  6.  In  either  case,  the  occurrence  of  uratic 
deposit  depends  on  the  insolubility  of  the  uric  acid  salt. 

This  view  binds  us  to  no  special  theory  as  regards  the 
chemical  antecedents  of  uric  acid,  whilst  it  serves  to  fix  in 
our  minds  the  points  on  which  our  treatment  should  be 
based. 

First,  to  promote  oxidation  so  as  to  ensure  the  destruc- 
tion of  uric  acid,  either  in  the  organs  and  tissues  in  which  it 
is  formed,  or  in  the  blood  into  which  it  has  passed.  The 
former  may  be  effected,  perhaps,  by  the  agency  of  drugs 
such  as  colchicum,  salicylic  acid,  etc.,  acting  through  the 
influence  of  the  vaso-motor  nerves  on  the  process  of  oxi- 


LITHUEIA. 


471 


dation;  the  latter  by  more  general  means,  such  as  exercise 
in  the  open  air,  spare  diet,  and.  the  use  of  alkalies,  which, 
as  is  well  known,  promote  oxidation  in  the  blood  current. 
Secondly,  to  prevent  the  ill  effects  of  the  deposited  uric 
acid  and  secure  its  removal,  by  the  administration  of 
solvents.  Of  these,  Dr.  Cook  has  shown  that  the  benzoates 
act  by  preventing  the  crystallization  of  uric  acid  and  its 
salts,  whilst  iodide  of  potassium,  salts  of  lithia,  etc.,  act 
probably  as  direct  solvents. 

The  following  summary  gives  some  of  the  chief  patho- 
logical and  clinical  conditions  which  lead  to  the  deposit  of 
uric  acid  or  urates  from  the  urine. 

A.  Deposits  of  uric  acid  or  urates,  not,  however,  necessarily 
eliminated  in  excessive  quantities. 


1.  Absolute  increase  ia 
the  acidity  of  the  urine. 


2.  Eelative  increase  in 
the  acidity  of  the  urine. 


The  occasional  deposit  of  urates  observed  in 
winter  arises  from  this  cause..  The  action  of 
the  skin  being  checked  the  acidity  of  the  urine 
increases  during  cold  weather.  Similarly  in 
many  extensive  cutaneous  diseases,  such  as  ec- 
zema and  psoriasis,  uric  acid  deposits  are  of  fre- 
quent occurrence;  these  disorders  therefore 
need  not  be  attributed  to  lithsamia.  Also  in 
forms  of  dyspepsia  associated  with  irregular 
secretion  of  gastric  juice. 

The  deposit  of  urates  frequently  noticed 
during  the  summer  months  originates  in  this 
■W'ay,  the  cutaneous  transpiration  being  in- 
creased in  hot  weather,  the  urine  is  more 
concentrated.  Similarly  in  pyrexia,  especially 
rheumatic  fever,  and  in  diarrhoaa.  Uric  acid 
deposits  alternating  with  sugar  are  often 
caused  in  this  way;  since  as  the  sugar  disap- 
pears urination  is  not  so  profuse,  and  a  relative 
increase  of  the  acidity  of  the  urine  occurs. 
This  relative  increase  may  not  only  be  caused 
by  a  diminution  of  the  water  excreted,  but 
from  deficiency  of  the  alkaline  phosphates ;  this 
condition  is  frequently  met  with  in  the  urines 
of  ill-nourished  or  strumous  children. 


472  DISEASES    OF    THE    KIDNEY. 

B,  Uric  acid  eliminated  in  excess,  hut  not  necessarily  de- 
posited from  the  urine. 

1.  Uric  acid  in  excess  Chiefly  in  diseases  of  the  liver,  such  as  acute 
usually  attended  with  a  yellow  atrophy,  cirrhosis,  and  cancer.  In 
diminution  of  the  other  scurvy  an  excess  of  uric  acid  is  generally  ob- 
urinary  constituents  served,  with  a  diminution  of  urea  and  the 
(true  litha°mia).  alkaline  phosphates. 

2.  Uric  acid  in  excess        In   functional   derangements    of  the    liver, 
attended     with     an    in-     especially  those  brought  about  by  disturbance 
crease  of  the  other  urin-     of  the  "  nitrogenous  equilibrium  "    by  the  in- 
ary  constituents.  gestionoftoo  much  animal  food.     Asa  con- 
dition   antecedent    to    the     development    of 
phthisis  or  cancer,  and  sometimes  of  diabetes, 
or  preceding  the  outbreak  of  such  constitu- 
tional conditions  as  syphilis,  scrofula,  and  of 
gout  in  its  early  attacks. 

1.  TJric  acid  calculi. — Calculi  mainly  composed  of  uric 
acid  are  the  most  frequent  of  all  urinary  concretions,  being 
]Dresent  in  some  form  or  other  in  at  least  80  per  cent,  of 
all  calcuU  that  come  under  observation.  This  frequency 
led  the  earlier  observers  to  consider  that  uric  acid  was  a 
necessary  constituent  of  all  stones,  and  they  beheved  it  to 
have  special  concreting  powers,  (concreting  acid),  in  con- 
sequence of  this  view  the  term  "  hthic  "  or  stone  acid  was 
given  it.  The  discovery,  however,  of  oxalate  of  lime  and 
phosphate  of  Hme  in  calculi,  solely  composed  of  these  sub- 
stances led  to  the  abandonment  of  this  error,  though  the 
term  is  still  erroneously  apphed.  Uric  acid  calculi  may 
be  large  and  solitary,  (fig.  37),  in  which  case  they  have  a 
smooth,  or  a  sHghtly  granular  surface,  of  a  yellow  or  red- 
dish-brown colour,  oval  in  shape,  and  range  in  size  from 
a  pigeon's  egg  to  that  of  a  hen's  Qgg,  on  section  they  are 
hard  and  brittle,  and  marked  with  concentric  laminae 
of  often  different  degrees  of  friability,  which  are  appar- 
ently determined  by  the  amount  of  organic  matter  pre- 


LITHURIA. 


473 


sent.  Medium  sized  and  multiple  calculi  are  like  the 
preceding,  only  smaller,  ranging  from  tliat  of  a  bean 
up  to  a  pigeon's  egg,  their  surface  is  often  facetted 
from  mutual  pressure.  Small  and  numerous  "pisiform" 
calculi  are  small,  yellowish,  rounded  bodies,  ranging 
in  size  from  a  pin's  point  to  that  of  a  marrowfat  pea, 
these  are  often  discharged  from  the  bladder  ia  con- 
siderable quantities,  especially  in  elderly  people.  The 
formation  of  these  small  calcuU  may  go  on  continuously 
for  some  time,  and  no  sooner  has  one  collection  passed 
than  another  forms  ;  any  one  of  these  small  stones  being 
retained  may  in  process  of  time  become  a  large  calculus. 


Fig.  37- — Uric  acid  calculus  showing  concentric  laminae. 

but  as  a  rule  it  will  be  found  that  the  larger  stones  have  a 
history  of  only  one  attack  of  colic,  and  if  removed  do  not 
usually  recur.  These  pisiform  concretions  seem  to  be 
intermediate  between  the  usual  form  of  calculus,  and 
gravel,  which  latter  consists  of  crystalline  aggregations  of 
uric  acid.  This  gravel  or  red  sand  may  accumulate  in  the 
pelvis  of  the  kidney,  or  in  the  lower  portions  of  the  ureters 
in  such  abundance  as  to  occasion  considerable  coHc,  and 
irritation  of  the  urinary  tract  in  its  passage.  The  ten- 
dency to  the  formation  of  uric  acid  calcuH  is  most  marked 
at  the  extremes  of  life,  i.e.,  in  children  and  elderly  per- 


474  DISEASES    OF    THE    KIDNEY. 

sons,  whilst  gravel  is  more  common  among  adults.  In  all 
cases  an  liiglily  acid  condition  of  the  urine  is  essential  for 
its  deposition  in  either  form,  and  the  close  relationship 
between  it  and  gout  has  long  been  recognised.  "We  have 
married  two  sisters,"  writes  Erasmus  to  a  friend,  "  you  have 
gout  and  I  have  gravel,"  and  this  observation  is  no  doubt 
true  as  regards  the  calculous  formations  of  uric  acid  in 
adult  life.  In  children,  however,  no  such  relationship 
exists,  for  though  the  children  of  a  gouty  stock  may  suffer 
from  calculous  and  uric  acid  deposits,  yet  in  a  vast 
majority  of  cases  no  such  connection  can  be  traced.  In 
children  calculus  is  more  frequently  the  result  of  some 
debilitating  illness,  and  from  the  very  highly  acid  urine 
secreted  by  them  under  very  slight  disturbing  influence. 
It  is  important  to  bear  this  in  mind,  since  the  tendency 
to  the  recurrence  of  stone  is  far  less  in  children  than 
in  elderly  persons.  With  regard  to  mixed  calculi  of  uric 
acid  \Yith  other  constituents,  that  of  phosphate  of  lime  is 
the  most  common,  then  oxalate  of  lime,  whilst  triple  phos- 
phate will  be  deposited  whenever  the  urine  becomes  alka- 
line from  ammoniacal  decomposition. 

2.  Urates. — These  bodies  are  very  uncommon  as  forming 
the  sole  constituent  of  stone,  especially  in  adults.  Mixed 
with  a  considerable  proportion  of  uric  acid  they  more  fre- 
quently occur  in  the  calculi  of  young  children ;  whilst  com- 
bined with  oxalate  of  lime  they  form  the  nucleus  in  fifty- six 
per  cent,  of  all  calculi  examined.  They  are  generally 
stated  to  consist  of  urate  of  ammonia,  but  analysis  shows 
that  urate  of  soda  and  urate  of  lime  are  also  present.  They 
never  attain  the  large  size  of  the  uric  acid  calculus,  but 
are  of  the  size  of  an  almond  to  that  of  a  good  sized  marble, 
generally  multiple,  two  or  three  being  usually  found  to- 
gether. Their  colour  is  light  fawn  or  greyish-yellow.  They 
are  less  compact  than  a  pure  uric  acid  calculus,  and  their 


LITHURIA.  '175 

nucleus  under  a  lens  often  presents  a  ragged  appearance. 
These  calculi  are  always  deposited  in  acid  urine,  except  a 
form  to  be  noticed  subsequently,  whicli  consists  of  a  mixture 
of  triple  phosphate  and  urate  of  ammonia,  and  which  is  as- 
sociated with  an  ammoniacal  condition  of  urine.     Urates 
sometimes  occur  as  gravel,  when  they  are  precipitated  in 
the  urinary  passages  as  spiked  granules,  but  their  chief 
interest  lies  in  their  forming  infarcts  in  the  renal  tubes  of 
young    infants.      These   consist   of  irregular   masses   of 
urate  of  ammonia  and  soda,  forming  yellowish-red  lines, 
which  radiate  from  the  papilla  to  the  bases  of  the  pyra- 
mids.    They  are  said  to  have  never  been  met  with  in  the 
kidneys    of   children    born    dead ;     they    usually    occur 
from  the  second  to  the  nineteenth  day  after  birth,  though 
in  some  instances  they  have  been  met  with  as  late  as  three 
or  four  months.      They  are  generally  regarded  as  physio- 
logical rather  than  pathological ;   they  are  no  doubt  de- 
posited from   a   concentrated    urine,   the   first   effort   of 
the   kidney   at   elimination,   for  just  as  meconium   con- 
sists  almost   entirely   of  biliary  matters  and  mucus,    so 
we  may  suppose  the  iirine  at  birth  to  consist  chiefly  of 
urates,  and  to  be  in  a  concentrated  condition  till  the  ^to- 
per   elaboration   of  the   urine   is  perfected  by  the  usual 
metabolic    changes   under    the   influence   of  respiration. 
These  infarcts  may  be  taken  for  the  granules  of  bilirubin 
sometimes  deposited  in  the  renal  cells  of  icteric  patients, 
or  granules  of  bilirubin  may  be  mixed  with  these  urates. 
Scattered  deposits  of  urates  are  frequently  found  in  the  gra- 
nular kidney,  these  are  most  frequent  in  the  cortex,  and  are 
apparently  not  connected  with  the  tubes,  whilst  in  the  so- 
called  "  gouty  kidney  "  the  deposits  occur  in  the  papillary 
portion  of  the  i^yramids,  and  are  decidedly  intra-tubular. 
Although  calculi  composed  mainly  of  uric  acid  are  fre- 
quent, and  those  of  urates  rare,  yet  with  regard  to  the 


476  DISEASES    OF    THE    KIDNEY. 

nucleus,  according  to  recent  observations,  the  reverse 
obtains,  a  mixture  of  urates  and  oxalates  being  the  most 
common. 

164.  Oxaluria. — There  are  few  subjects  in  urinary 
pathology  which  have  excited  keener  controversy  than  that 
which  concerns  the  causes  tending  to  produce  a  deposit  of 
oxalate  of  lime  crystals  in  urine.  Originally  discovered  by 
Wollaston,  in  1803,  as  the  constituent  of  the  mulberry 
variety  of  calculus,  its  presence  as  a  crystalline  deposit  in 
the  urine  was  for  a  long  time  overlooked.  In  1842,  Dr. 
Golding  Bird,  in  the  "Medical  Gazette,"  drew  attention  to 
the  fact  that  oxalate  of  lime  was  frequently  present  as  a 
crystalline  deposit  in  urine,  and  detailed  a  series  of  ner- 
vous and  dyspeptic  symptoms  which  he  alleged  were  asso- 
ciated with  the  appearance  of  this  salt  in  the  urine,  and 
which  he  supposed  to  be  intimately  connected  with  an  in- 
creased production  of  oxalic  acid  in  the  system.  Dr. 
Golding  Bird's  observations  were  at  first  accepted  with 
some  degree  of  hesitation,  but  subsequently  they  received 
the  support  of  Beneke  and  Begbie.  As  more  extended 
observations  were  made  it  was  found  that  crystals  of 
oxalate  of  lime  were  of  very  frequent  occurrence,  that  they 
were  found  in  urine  under  a  variety  of  pathological  con- 
ditions, that  they  were  so  far  from  being  invariably  asso- 
ciated with  a  train  of  nervous  and  dyspeptic  symptoms 
that  they  were  frequently  met  with  in  the  urine  of  persons 
apparently  enjoying  robust  health.  Hereupon  a  reaction 
ensued,  and  the  opinion  gained  ground  that  these  deposits 
had  no  clinical  significance  whatever,  and  it  was  even 
questioned  whether  the  oxaHc  acid  found  in  the  urine 
ever  existed  in,  or  was  excreted  as  such,  from  the  blood, 
and  it  was  suggested  that  oxalic  acid  was  merely  a 
product  produced  by  changes  occurring  in  the  urine  after 
emission.     In  England  these  views  have  been  advocated 


OXALUEIA.  477 

by  Basliam,  Bence  Jones,  and  Owen  Eees,  The  latter 
gentleman  goes  so  far  as  to  regard  "oxalate  of  lime  merely 
as  uric  acid,  or  urate  altered  after  secretion,"  and  states 
that  he  has  entbely  failed  to  detect  the  peculiar  patho- 
logical conditions  which  have  been  said  to  connect  them- 
selves with  the  so-called  oxalic  acid  diathesis,  and  is  con- 
vinced that  it  must  be  regarded  as  an  accidental  and 
unimportant  modification  of  that  most  significant  variation 
from  health  which  consists  in  the  excretion  of  uric  acid,  or 
its  compounds,  in  abnormally  increased  proportion.  Facts 
which  we  will  now  consider,  however,  are  now  known 
which  point  to  the  conclusion  that  oxalic  acid  is  formed  in 
the  organism  and  excreted  with  the  urine,  and  that  uric 
acid,  though  it  may  be  a  factor,  is  not  the  only  source 
from  which  it  is  derived,  either  by  oxidation  within  the 
system  or  by  decomposition  after  it  has  been  excreted. 
The  following,  then,  are  the  chief  pathological  and  clinical 
conditions,  under  which  oxalic  acid  combined  with  lime 
makes  its  appearance  in  the  urine  as  a  deposit  of  calcium 
oxalate. 

1.  Directly  from  food  by  the  ingestion-  of  substances  contain- 
ing oxalate  of  lime. — It  is  a  well-known  fact  that  oxalate  of 
lime  crystals  have  been  found  in  abundance  in  the  urine  of 
persons  who  have  attempted  to  poison  themselves  with 
oxalic  acid  ;  and  experiments  have  shown  that  when  non- 
poisonous  doses  are  taken  about  twelve  per  cent,  of  the 
acid  taken  by  the  mouth  appears  as  a  lime  salt  in  the 
urine.  Many  fruits  and  vegetables,  such  as  rhubarb, 
sorrel,  tomatoes,  onions,  and  turnips,  contain  crystals  of 
oxalate  of  lime  ;  and  to  many  persons  in  weak  health,  in- 
dulgence in  such  articles  is  invariably  followed  by  an 
attack  of  indigestion  and  the  appearance  of  crystals  of 
oxalate  of  lime  in  the  urine.  It  has,  however,  been  urged 
that  oxalate  of  lime  cannot  thus  be  absorbed  from  the  in- 


478  DISEASES    OF    THE    KIDNEY. 

testine  into  the  system  and  pass  out  iinclianged  into  the 
urine,  on  account  of  its  great  insolubility  in  water.  Eeoch, 
however,  has  demonstrated  that  the  insolubiUty  is  exag- 
gerated, and  he  points  out  that  Storer,  in  his  "Dictionary 
of  Solubilities,"  gives  the  solubihty  of  oxalate  of  lime  in 
water  as  -g-o oVo o-  This,  no  doubt,  appears  small ;  but  as 
oxalates  are  never  recognisable  without  the  microscope  and 
seldom  appear  larger  than  a  blood  corpuscle,  so  that,  as 
Eeoch  argues,  by  taking  the  specific  gravity  of  an  average 
crystal  as  equal  to  a  cube  of  water  -g-^oo  ^^  ^^  ^^^^  ^ 
the  side,  since  cubes  are  to  one  another  as  the  cubes 
of  their  sides,  it  follows  that  a  cubic  inch  of  water  would 
be  equal  to  27,000,000,000  of  these  crystals,  and  would 
therefore,  according  to  Storer,  dissolve  54,000  ;  and  ten 
ounces  of  water  would  dissolve  1,000,000  of  these  crystals ; 
hence,  as  we  do  not  often  meet  with  a  larger  proportion 
than  this  in  the  urine,  the  amount  of  blood  cu'culating  in 
the  body  is  more,  considerably  more,  than  sufficient  to 
keep  this  quantity  in  solution.  Urines  containing  oxalate 
of  lime  dh-ectly  derived  from  the  food  are  rarely  altered  in 
their  general  characters,  and  the  crystals  cease  to  be 
deposited  at  no  very  distant  period  after  their  ingestion. 
No  sense  of  discomfort  may  be  occasioned  by  their  passage 
through  the  system,  at  most,  a  mere  passing  attack  of  in- 
digestion or  increasing  urgency  during  micturition,  if  there 
be  any  urethral  or  vesical  disease,  caused  by  the  passage  of 
the  ci-ystals  over  tlie  already  sensitive  mucous  membrane. 
2.  hiclirectly  from  food,  incomplete  oxidation  of  the  saceha- 
rine,  amylaceous,  and  oleaginous  principles  of  the  food. — 
Before  their  final  conversion  into  carbonic  acid  and  water, 
these  principles  yield  several  intermediary  non-nitrogen- 
ous acids,  of  which  the  chief  are  glycoUic,  lactic,  and 
oxaHc  acids.  The  albuminous  princi^^les,  besides  yielding 
certain  nitrogenous  bodies,  as  leucin,  kreatiu,  uric  acid, 


OXALUEIA.  479 

and  urea,  also  furnisli  a  series  of  non-nitrogenous  fatty 
acids  similar  to  those  obtained  from  the  saccharine  and 
amylaceous  principles.  Now,  in  the  downward  progress  of 
these  acids  towards  their  lowest  term,  carbonic  acid  and 
water,  it  is  quite  possible  that  arrest  of  oxidation  may 
take  place  at  any  one  of  them ;  and  that  whilst  perfectly 
normal  action  produces  carbonic  acid  and  water,  a  check 
to  the  process  will  lead  to  the  appearance  of  oxalic  acid  in 
the  urine.  Indeed,  it  is  probable  that  there  are  many 
conditions,  within  physiological  limits,  in  which  power  is 
economised  in  the  system  by  eliminating  the  lower  oxi- 
dized product,  oxalic  acid,  by  the  urine,  instead  of  in  its 
completely  oxidised  state,  as  carbonic  acid,  by  the  lungs. 
Oxalic  acid  formed  under  these  circumstances  will  only 
occasionally  be  present  in  the  urine,  and  will  often  appear 
and  disappear  without  any  apparent  alteration  in  health. 
"When  the  crystals  of  oxalate  of  lime  are  deposited  in  these 
cases,  they  will  be  found  in  the  urine  passed  within  a  few 
hours  after  food,  their  j)resence  often  inducing  profuse 
urination. 

3.  From  increased  tissue  metabolism. — As  stated  above,  the 
albuminous  principles  by  oxidation  break  up  into  two 
parallel  series ;  nitrogenous  bodies  and  non-nitrogenous 
fatty  acids.  When,  therefore,  increased  metabohsm  of 
tissue  occurs  within  the  body,  we  have  an  increase  of 
these  products  in  the  urine.  This  is  probably  the  most 
frequent  cause  of  the  appearance  of  oxalate  of  hme  de- 
posits in  the  urine,  and  they  are  met  with  under  a  variety 
of  pathological  conditions,  frequently  during  the  course  of 
most  febrile  diseases,  in  pulmonary  and  cardiac  affections 
in  which  resph'ation  is  impeded,  and  in  disorders  of  the 
hepatic  functions  and  depressed  conditions  of  the  nervous 
system.  The  urines  in  these  cases  are  generally  of  a  deex^ 
orange  colour,  of  high  average  specific  gravity,  with  an 


480  DISEASES    OF    THE    KIDNEY. 

excess  of  urea  and  phosphoric  acid,  and  are  usually  turbid 
with  mucus  and  urates,  while  the  deposits  of  oxalate  are 
not  usually  persistent,  often  disappearing  for  a  few  days,' 
to  return  again  in  great  abundance.  The  oxalic  acid  in 
this  case  probably  is,  from  reasons  already  stated,  not  de- 
rived from  the  decomposition  of  uric  acid,  either  in  the 
blood,  or  subsequently  in  the  urine  after  emission.  The 
most  rational  explanation  of  its  appearance  being,  that  the 
process  of  oxidation  within  the  body,  under  circumstances 
of  increased  tissue  metabolism,  is  only  sufiicient  to  reduce' 
a  certain  quantity  of  non-nitrogenous  fatty  acids  formed 
within  the  body  to  then-  lowest  term  of  carbonic  acid,  and 
consequently  oxalic  acid,  which  is  one  of  the  series,  ap- 
pears in  the  urine. 

4.  From  the  mucus  of  the  urinary  passages. — Crystals  of 
oxalate  of  lime  have  been  found  in  the  mucus  of  the  gall- 
bladder and  in  the  gravid  uterus,  and  it  has  therefore  been 
suggested  that  the  crystals  that  appear  in  the  urine  may 
have  their  origin  in  the  mucus  of  the  genito- urinary 
passages.  In  some  cases  this  is  probably  true,  but  in  the 
majority  of  instances  we  have  no  evidence  of  any  morbid 
condition  of  the  urinary  passages  to  account  for  their  ap- 
pearance. It  is  probable,  however,  that  calculi  composed  of 
oxalate  of  lime  may  result  from  chemical  changes  taking 
place  in  the  mucus  of  the  urinary  passages,  for,  as  Professor 
Partes  [op.  cit.)  has  remarked,  "no  one  can  observe  the  enor- 
mous amount  of  oxalic  acid  in  calculi,  and  beheve  that  such 
abundance  could  ever  come  from  the  blood."  A  very  in- 
genious hypothesis  has  been  advanced  by  Meckel  to 
account  for  this  formation  of  oxalate  of  lime  in  mucus,  by 
assuming  that  the  mucous  membrane  of  the  urinary  pas- 
sages becomes  the  seat  of  a  specific  catarrh.  In  this 
catarrh  a  tough  adhesive  mucus  is  secreted,  which  has  a 
tendency  to   undergo   acid  fermentation,   and  in   which 


OXALURIA.  481 

oxalate  of  lime  appears  when  such  fermentation  occurs. 
At  first  this  oxalate  of  lime  mucus  is  of  gelatinous  consist- 
ence, but  gradually  it  takes  tip  more  and  more  oxalate  of 
lime  from  the  decomposed  urine,  and  thus,  growing  more 
and  more  firm,  a  stony  concretion  is  at  length  formed. 
The  large  and  numerous  crystals  of  oxalate  of  hme  so  fre- 
quently observed  in  the  urine  of  persons  suffering  from 
spermatorrhoea,  are  most  probably  derived  from  the  mucus 
of  the  genito-urinary  passages ;  for  if  a  patient  suffering 
from  this  malady  be  directed  to  collect  the  urine  passed  at 
stool  in  a  small  vessel,  and  also  the  seminal  and  mucous 
discharge  which  generally  follows  micturition  during  the 
act  of  defecation,  separately  in  a  test-tube  or  on  glass-slide, 
it  will  be  found  that  both  the  urine  and  the  discharge  con- 
tain oxalates,  which  are,  moreover,  intimately  mixed  up  in 
the  latter,  thus  indicating  an  intrinsic  origin.  It  is  not 
improbable  that  the  oxalate  of  lime  deposits  so  frequently 
observed  in  the  urines  of  ataxic  patients,  especially  during 
the  so-called  urinary  crises,  may  originate  in  this  way, 
owing  to  an  abnormal  condition  of  the  mucous  membrane 
of  the  urinary  passages  resulting  from  disturbed  innerva- 
tion. 

5.  From  excess  of  acid  in  the  system. — Beneke  {op.  cit.) 
has  pointed  out  that  the  increased  production  of  lactic  and 
butyric  acids  in  the  alimentary  canal  is  frequently  asso- 
ciated with  oxaluria,  since,  as  he  thinks,  the  excessive 
formation  of  these  acids  prevents  the  development  of  the 
red  corpuscles,  so  that  oxidation  is  insufficiently  performed. 
A  catarrhal  condition  of  the  mucous  membrane  of  the 
intestines  he  also  pointed  out  as  being  frequently  found 
accompanying  this  condition  ;  he  does  not,  however,  con- 
sider it  as  being  a  proximate,  but  only  a  determining, 
cause  of  the  disorder.  Whilst  endorsing  Beneke's  state- 
ment that  deposits  of  oxalate  of  lime  are  met  with  in  per- 


482  DISEASES    OF    THE    KIDNEY. 

sons  suffering  from  dyspepsia,  attended  with  excessive  for- 
mation of  lactic  and  butyric  acids,  I  do  not  consider  his 
explanation  to  be  the  correct  one,  since  in  these  cases  I 
believe  a  catarrhal  condition  of  the  mucous  membrane  of 
the  digestive  canal  to  be  the  proximate  cause,  which,  by 
hindering  the  onward  passage  of  the  food,  favours  fermen- 
tative changes  and  the  production  of  lactic  and  butyric 
acids.  These  acids,  which  are  formed  in  small  quantities 
in  the  large  intestine  in  health,  being  absorbed  into  the 
blood,  are  normally  reduced  to  carbonic  acid,  which  under 
ordinary  circumstances  passes  off  with  the  other  carbonic 
acid  formed  in  the  body  by  the  lungs.  If,  however,  the 
process  of  respiration  be  at  all  impeded,  some  of  the  car- 
bonic acid  may  be  eliminated  by  the  urine,  combined  with 
the  oxides  of  potash  and  soda,  in  the  form  of  alkaline  car- 
bonates, causing  an  alkaline  condition  of  that  secretion.* 
Or  if  the  acids  absorbed  from  the  intestinal  canal  into  the 
circulation  be  formed  in  excess,  their  reduction  into  car- 
bonic acid  may  be  incompletely  performed,  and  so  the 
intermediate  acid,  oxalic,  appears  in  the  urine  in  combina- 
tion with  lime.  It  is  this  condition,  and  this  condition 
alone,  to  which  I  think  the  term  "oxaluria"  may  be 
clinically  applied  with  a  fair  show  of  reason,  since  the 
chief  and  most  persistent  urinary  phenomenon  is  the  de- 
posit of  oxalate  of  lime  crystals  in  the  urine. 

The  symptoms  attendant  on  oxaluria,  are  in  typical 
cases  sufficiently  characteristic  to  distinguish  them  from 
those  which  accompany  the  derangements  associated  with 
deposits  of  uric  acid,  and  which  the  late  Dr.  Murchison 
{op.  cit.)  so  graphically  portrayed  in  his  account  of  the 
condition  he  termed  "lithaemia."  Thus  the  sufferers  from 
oxaluria  are  to  be  found  chiefly  among  the  careworn,  the 

*  Lancet,  July,  1880.  "A  Form  of  Dyspepsia  associated  with 
an  Alkaline  Condition  of  the  Urine."     By  the  Author. 


OXALURIA.  483 

harassed,  tlie  overworked,  and  underpaid  members  of  the 
community,  and  form  a  marked  contrast  in  appearance  to 
the  generality  of  those  troubled  with  uric  acid  tendencies ; 
whilst  high  living  combined  with  sedentary  habits  tends  to 
promote  a  condition  of  "-lithsemia,"  so  that  persons  suffer- 
ing from  that  form  of  dyspepsia,  instead  of  feeling  re- 
freshed by  food,  are  seized  '^'  with  a  feeling  of  oppression, 
often  of  weariness  and  aching  pains  in  the  limbs,  and  an 
insurmountable  sleepiness  after  meals  "  (Murchison).  On 
the  other  hand,  patients  with  oxaluria  feel  for  a  time 
better  after  food  and  improve  on  a  generous,  if  suitably 
selected,  dietary.  Again,,  a  tendency  to  uric  acid  deposits 
is  more  frequently  met  with  among  dwellers  in  towns, 
whilst,  as  far  as  my  experience  goes,  the  victims  of  oxal- 
uria are  most  frequently  country  patients,  especially  those 
residing  in  damp  and  marshy  districts,  or  on  cold  ill- 
drained  clay  soils  :  situations,  in  fact,  in  which  catarrhal 
affections  of  the  intestinal  canal  are  likely  to  be  engendered. 
Although  in  both  conditions  the  mental  state  is  more  or 
less  affected,  still  it  assumes  a  different  aspect  in  each. 
In  "lithsemia"  the  patient  is  irritable,  fretful^  peevish,  and 
discontented  with  those  around  him,  but  he  is  rarely  at 
fault  with  himself  or  hypochondriacal.  In  oxaluria,  how- 
ever, the  patient  is  generally  amiable  and  easy  tempered 
with  his  relations  and  dependents,  but  is  himself  filled 
with  the  deepest  gloom  and  forebodings,  and  is  painfully 
hypochondriacal.  In  oxaluria  the  bowels  are  irregular, 
constipation  at  times  alternating  with  a  colicky  diarrhoea 
of  frothy,  yeasty  character,  and  not  infrequently  accom- 
panied with  considerable  discharges  of  blood.  The  urine 
is  usually  of  a  pale  greenish  colour,  and  the  quantity 
passed  in  the  twenty-four  hours  normal  in  quantity  and 
specific  gravity.  Its  chief  characteristic  is  the  deposit  of 
crystals  of  oxalate  of  lime,  which  are  found  most  abun- 

II  2 


484  DISEASES    OF    THE    KIDNEY. 

dantly  in  the  morning  urine  passed  on  first  rising.  Owing 
to  the  presence  of  these  crystals  causing  irritation  of  the 
mucous  membrane  of  the  bladder,  micturition  is  frequent 
and  urgent,  though  the  quantity  of  urine  passed  is  not 
large.  Traces  of  sugar  are  not  infrequently  present,  and 
sometimes  sugar  for  a  while  replaces  the  deposit  of  oxal- 
ates, and  vice  versa.  This  transformation  has  been  ac- 
counted for  by  the  hypothesis,  that  whilst  oxalic  acid 
denoted  a  condition  of  imperfect  oxidation,  sugar  repre- 
sented a  still  lower.  The  appearance  therefore  of  oxalates 
with  a  diminution  of  the  excretion  of  sugar  has  frequently 
been  taken  as  a  favourable  symptom  of  diabetes,  an 
opinion,  however,  which  I  do  not  think  altogether  war- 
ranted. The  urine  occasionally  contains  an  excess  of 
phosphate  of  lime,  though  this  condition  is  not  nearly  so 
frequently  observed  in  this  form  of  oxaluria  as  in  the  case 
where  the  deposit  of  oxalate  of  lime  results  apparently 
from  increased  tissue  metabolism,  and  in  which,  as  has 
been  already  stated,  an  increase  of  urea  is  also  generally 
noted.  Various  reasons  have  been  assigned  to  account 
for  the  association  of  deposits  of  oxalates  with  occasional 
excess  in  the  elimination  of  phosphate  of  lime  in  the  urine. 
The  most  probable  explanation  is  that  it  originates  in  two 
ways : — a.  In  those  cases  where  there  is  an  excess  of  urea 
the  increase  in  the  elimination  of  the  phosphoric  acid  is 
the  result  of  the  increased  metabolism  of  the  tissues  gene- 
rally, h.  Where  the  deposits  of  oxalate  of  lime  are  associ- 
ated with  catarrh  of  the  intestinal  canal,  and  the  forma- 
tion of  lactic  and  butyric  acids  is  excessive,  the  phosphate 
of  lime  is  derived  not  from  the  tissues,  but  from  the  ali- 
mentary canal,  the  lactic  acid  having  a  powerful  solvent 
action  on  this  salt ;  so  that  if  it  is  introduced  in  excess 
with  the  food,  a  larger  proportion  will  be  dissolved  out  and 
pass  into  the  system  than  would  otherwise  be  the  case. 


OXALUKIA.  485 

In  addition  to  the  mental  depression  already  mentioned, 
patients  suffering  from  this  form  of  oxaluria  are  troubled 
with  many  anomalous  symptoms  indicative  of  nervous 
disturbance.  Thus,  a  burning  sensation  is  usually  felt 
across  the  loins,  accompanied  by  a  feeling  of  tightness  and 
dragging  round  the  abdomen,  shooting  and  burning  pains 
in  the  lower  limbs,  twitching  of  certain  groups  of  muscles, 
with  often  a  feeUng  of  numbness,  deadness,  and  coldness 
in  different  parts  of  the  body.  These  symptoms,  when 
present  together,  may  lead  us  to  infer  that  the  patient  is 
suffering  from  an  early  stage  of  locomotor  ataxy,  as  was 
the  case  with  an  out-patient  under  my  care  at  the 
London  Hospital,  when  he  first  came  under  observa- 
tion. The  fact,  however,  that  other  characteristic  symp- 
toms were  absent,  and  did  not  develop,  and  that  he 
improved  on  a  treatment  directed  to  the  relief  of  the 
dyspeptic  condition,  soon  dispelled  any  doubts  on  that 
point.  In  another  case  the  patient  had  been  actually 
treated  for  some  time  for  incipient  locomotor  ataxy,  and 
also  for  syphilitic  disease  of  the  spinal  cord,  his  symp- 
toms being  ultimately  relieved  by  the  discharge  of  a  small 
concretion  of  oxalate  of  lime  (p.  512). 

Oxalate  of  lime  calculi  present  themselves  in  two  forms. 
The  most  common,  a  large  roagh  calculus  commonly 
called  the  "mulberry  calculus"  (figs.  38,  39),  and  less 
frequently  as  numerous  small  rounded  concretions,  re- 
sembling and  known  as  "hemp-seed"  calculi.  The  mul- 
berry calculus  often  attains  a  considerable  size.  It  has  a 
rough  irregular  surface,  and  is  of  a  dark  colour.  It  is 
extremely  hard,  and  on  section  (fig.  39)  presents  an 
angular  structure  with  dark  coloured  laminse,  which  are 
very  compact,  and  are  often  marked  with  fine  parallel 
lines.  The  nucleus  most  commonly  consists  of  a  mixture 
of  urates,  uric  acid  and  oxalate  of  lime ;  more  frequently, 


486  DISEASES    OF    THE    KIDNEY. 

however,  than  with  other  calcuh  the  nucleus  is  sometimes 
purely  hsemic.  Although  calculi  of  pure  oxalate  of  lime 
are  by  no  means  rare,  still  it  is  most  frequently  mixed 
with  other  constituents,  the  most  frequent  is  that  of 
oxalate  of  lime  and  uric  acid  in  alternating  layers  round  a 


Fi^G.  38. — Mulberry  calculus — oxalate  of  lime. 

mixed  nucleus  of  both  substances  (fig.  40),  whilst  next 
in  frequency  comes  the  calculus  formed  by  an  external 
crust  of  calcium  and  triple  phosphate  on  a  mass  of  oxa- 
late of  lime,  these  calculi  often  attain  a  prodigious  size. 


Fig.  39. — Section  of  mulberry  calculus. 

Oxalate  of  lime  is  sometimes,  but  very  rarely,  deposited 
on  other  calcah  in  a  crystalhne  form  [Path.  Soc.  Trans., 

vol.  XXV.). 

The  small  "hemp- seed"  calculi  vary  in  size  from  a  pin's 


CYSTINUEIA. 


487 


head  to  that  of  a  hemp- seed,  smooth  and  dark  coloured. 
They  are  often  discharged  in  considerable  numbers,  and 
like  the  pisiform  calculi  of  uric  acid,  the  tendency  to  form 
is  long  continued. 


Fig.  40.- 


-Calculus  composed  chiefly  of  uric  acid  ;   with  a  mixed  nucleus 
of  uric  acid  and  oxalate  of  lime. 


165.  Cystinuria. — Cystin  calculi  are  comparatively 
rare  in  actual  practice,  though  if  we  judge  from  the  num- 
bers preserved  in  pathological  museums,  we  should  think 
them  by  no  means  uncommon.  Cystin  calcuh  rarely 
attain  to  considerable  size  Hke  uric  acid,  or  phosphatic  cal- 
cuh, but  are  generally  of  medium  size  ;  they  are  usually 
oval,  but  some  times  cylindrical ;  their  surface  is  finely 
granular,  with  small  crystals  often  dispersed  over  it  of  a 
pure  yellow  colour ;  they  break  with  a  crystalline  fracture, 
and  are  soft  and  somewhat  compressible.  Their  cut  sec- 
tion presents  a  yellow  colour,  turning  pale  green  on  ex- 
posure to  Hght,  with  a  somewhat  radiated  appearance. 
Usually  they  consist  entirely  of  cystin,  but  some  have  a 
nucleus  of  uric  acid  on  which  the  cystin  is  deposited,  cys- 
tin also  occurs  as  a  urinary  deposit  and  as  gravel.  The 
urine  in  these  cases  has  generally  a  yellowish-green 
colour,  and  a  peculiar  smell  said  to  be  like  sweet  briar 
when  fresh,  but  rapidly  acquiring  a  putrescent  smell  when 
kept,  whilst  an  oily  looking  film  speedily  forms  on  the  sur- 
face. Should  the  urine  be  acid  at  the  time  of  passing,  the 
cystin  may  be  kept  in  solution,  but  as  soon  as  ammoniacal 


488  DISEASES    OF    THE    KIDNEY. 

decomposition  sets  in  it  will  be  deposited ;  since,  though 
cystin  is  freely  soluble  in  ammonia,  it  is  not  so  in  car- 
bonate of  ammonia  or  any  of  the  alkaline  carbonates. 
Some  observers  have  stated  that  urines  containing  cystin 
are  poor  in  urea  and  uric  acid.  The  conditions  under 
which  cystin  calculi,  and  gravel,  are  formed  in  the  urinary 
passages  is  not  yet  determined.  Heredity  seems  to  have 
some  influence,  undoubtedly  it  is  frequently  met  with  in 
the  members  of  the  same  family.  From  its  containing 
sulphur,  and  the  close  correspondence  that  exists  between 
its  elementary  composition  and  that  of  taurin,  it  has  been 
supposed  that  under  certain  circumstances  its  excretion 
compensates  for  the  deficient  action  of  the  liver  in  the 
elimination  of  sulphur.  The  view  I  am  disposed  to  take, 
is  that  cystin  is  formed  directly  from  taurin,  in  a  manner 
perhaps  analogous  to  the  formation  of  indigo  from  indol. 
The  observations  of  Naunym  and  Dragendorff  have 
shown  that  normal  urine  contains  traces  of  bile  acids, 
of  which  glycochohc  acid  is  the  chief,  so  that  it  is  probable 
that  some  portion  of  the  taurocholic  acid  is  oxidized,  and 
furnishes  the  partially  oxidized  sulphur  product,  which 
in  minute  quantities  is  always  present  in  normal  urine. 
Moreover,  Dr.  Oliver  has  recently  shown,  by  means  of 
his  peptone  test,  that  the  bile  acids  are  often  enormously 
increased  in  the  urine  in  many  morbid  conditions,  especially 
those  connected  with  functional  derangements  of  the  liver 
and  anaemia  (Lancet,  April  and  May,  1885).  It  may  be, 
therefore,  that  under  certain  conditions,  the  quantity  of 
taurin  eliminated  by  the  kidney  is  increased,  or  its  excre- 
tion checked,  whilst  the  transformation  into  unoxidised 
sulphur  is  incompletely  carried  out,  so  the  intermediate  pro- 
duct cystin  is  the  result.  However  that  may  be,  the  frequent 
association  of  cystinuria  with  some  disorder  of  the  hepatic 
functions  has  been  fairly  established.      Prout  regarding 


PHOSPHATURIA.  489 

the  peculiar  tallowy  and  waxy  character  of  the  complexion 
so  frequently  noticed  in  these  cases,  suggested  the  proba- 
bility of  its  connection  with  fatty  liver.  Cystin  calculi  and 
cystin  gravel  have  been  frequently  met  with  in  patients 
whose  kidneys  have  undergone  extensive  disorganisation. 
Strumous  children  are  said  to  be  especially  liable  to  de- 
posits of  cystin,  and  it  has  been  frequently  found  in  the 
urine  of  chlorotic  females.  Benefit  is  experienced  by  the 
employment  of  oxidising  remedies,  sea  bathing,  iron,  and 
nitro-muriatic  acid.  All  these  circumstances,  as  well 
as  the  statement  that  the  amount  of  urea  excreted  is 
diminished  in  these  cases,  strengthens  the  view  that  the 
formation  of  cystin  depends  on  a  local,  as  well  as  a 
general,  deficiency  of  oxidation. 

166.  Xanthin  calculi  are  the  rarest  of  all  urinary  con- 
cretions. In  all  recorded  instances  they  have  been 
removed  from  young  persons.  The  largest  calculi  was 
that  removed  by  Langenbeck  from  a  boy  aged  eight,  and 
was  the  size  of  a  small  egg.  The  stone  in  the  College 
of  Surgeons,  analysed  by  Mr.  Taylor,  weighed  when  entire 
a  quarter  of  an  ounce,  and  was  taken  from  a  child  aged 
four.  These  stones  are  smooth  and  of  a  cinnamon  colour, 
and  acquire  a  polish  when  rubbed.  A  few  cases  of  xanthin 
gravel  have  been  recorded,  these  all  occurred  in  young 
persons.  Dr.  Bence  Jones  considers  that  the  tendency  to 
deposit  xanthin  in  youth  is  to  be  explained  by  the  fact,  that 
it  is  in  the  earlier  period  of  life,  the  greatest  chemical 
variations  of  the  body  are  to  be  expected,  and  the  imperfect 
oxidation  of  xanthin  into  uric  acid  most  likely  to  occur. 

167.  Phosphaturia. — We  have  already,  when  con- 
sidering the  chemistry  of  the  alkaline  and  earthy  phos- 
phates (p.  90),  stated  that  only  the  latter  are  deposited, 
and  that  this  deposition  occurs  under  three  conditions.  1. 
When  the  urine  is  alkahne  from  Jixed  alkali  as  when  the 


490  DISEASES    OF    THE    KIDNEY. 

carbonates  of  potash  and  soda  are  in  excess  in  the  urine. 
2.  When  the  earthy  phosphates  are  themselves  ehminated 
in  excess.  3.  When  the  urine  is  alkaHne  from  volatile 
alkali,  as  when  owing  to  the  decomposition  of  the  urea  in 
the  urinary  passages  carbonate  of  ammonia  is  formed, 
which  combines  with  magnesium  phosphate  to  form  the 
triple  salt  ammonio-magnesium  phosphate.  Each  of 
these  conditions  must  now  be  considered  seriatim. 

1.  Deposit  of  earthy  phosphates  when  the  urine  is  alkaline 
from  fixed  alkali. — The  urine  is  usually  alkaline  when 
passed,  and  is  slightly  cloudy  from  the  precipitated  calcium 
phosphate,  though  it  does  not  necessarily  contain  an  ex- 
cess of  this  body.  The  urine  is  usually  increased  in 
quantity.  The  specific  gravity  is  above  the  average,  and 
the  urine  effervesces  when  hydrochloric  acid  is  added,  the 
deposited  phosphates  at  the  same  time  clearing  up.  Very 
frequently  it  happens  that  owing  to  a  partial  deposition  in 
the  bladder  of  the  calcium  phosphate,  the  phosphates  are 
discharged  like  a  creamy  fluid  at  the  end  of  micturition, 
the  passage  giving  rise  to  a  considerable  amount  of  irrita- 
tion at  the  neck  of  the  bladder.  Patients  very  often  con- 
sider this  creamy  discharge  an  evidence  of  spermatorrhoea, 
but  it  has  no  connection  with  that  condition,  and  a  few 
drops  of  hydrochloric  acid  will  at  once  clear  up  the  deposit, 
and  make  its  character  evident.  Occasionally  it  happens 
that  the  urine  instead  of  being  alkaline  is  slightly  acid ; 
when  this  is  the  case  the  phosphates  are  not  deposited 
unless  the  urine  is  boiled,  when  it  at  once  becomes  turbid 
from  the  precipitation  of  the  calcium  phosphate.  The 
cause  of  this  deposition  of  phosphate  on  boiling  is  explained 
at  p.  94.  Urines  depositing  calcium  phosphate  often  con- 
tain an  excess  of  uric  acid,  but  so  long  as  the  secretion  con- 
tinues alkaline  the  uric  acid  will  not  of  course  be  deposited, 
but  should  the  urine  become  acid  it  will  crystallize  out.  This 


PHOSPHATURIA.  491 

has  made  some  physicians  consider  that  the  two  conditions 
alternate,  but  in  reahty  it  only  depends  on  the  alteration 
in  the  reaction  of  the  urine,  for  if  we  render  the  urine 
artificially  acid  when  it  is  alkaline,  an  abundance  of  uric 
acid  will  generally  crystallize  out.  The  conditions  leading 
to  the  passage  of  urine  alkaline  from  excess  of  the  fixed 
alkalies  have  been  already  considered  (p.  62).  They  are 
generally  met  with  in  debilitated  persons,  and  those  suf- 
fering from  flatulent  dyspepsia. 

2.  Deposit  of  calcium  phosphate  from  excessive  elimination. 
— In  these  cases  both  the  alkaline  and  earthy  phosphates 
are  eliminated  in  increased  quantities,  the  total  amount  of 
phosphoric  acid  excreted  in  twenty-four  hours  being  often 
as  much  as  7  or  9  grms.,  instead  of  the  normal  amount  2*5 
to  3  grms.  The  urines  are  generally  alkaline,  copious, 
of  medium  specific  gravity,  and  deposit  a  dense  mealy 
precipitate  of  phosphate  of  lime,  this  being  partially  de- 
posited in  the  bladder ;  the  last  portion  of  the  urine 
passed  is  much  thicker  than  the  first  and  consequently 
comes  away  with  great  straining  and  irritation.  Occasion- 
ally, the  urine  is  acid,  so  that  no  deposit  occurs,  and  till  a 
quantitative  estimation  is  made  it  is  impossible  to  tell  that 
phosphoric  acid  is  draining  away  from  the  body  in  such 
quantities.  When  we  have  to  deal  with  the  persistent 
elimination  of  phosphoric  acid  in  excessive  quantities, 
very  distressing  constitutional  symptoms  are  associated 
with  its  discharge.  The  symptoms  vary  considerably  in 
individual  cases,  but  they  are  all  more  or  less  character- 
ised by  great  nervous  irritability,  derangements  of  diges- 
tion, great  emaciation,  severe  aching  pains  in  the  back 
and  loins,  especially  affecting  the  pelvic  viscera.  As  the 
disease  advances,  symptoms  analogous  to  those  of  dia- 
betes, especially  of  the  insipid  form,  make  their  appear-, 
ance ;    indeed,  the  disease  seems  to  merge  into  that  con- 


492  DISEASES    OF    THE    KIDNEY. 

dition,  insomuch  that  it  has  been  proposed  to  give  to  this 
disorder  the  distinctive  title  of  "phosphatic  diabetes"  (see 
Polyuria,  p.  400). 

With  regard  to  the  conditions  that  lead  to  this  exces- 
sive elimination  of  phosphoric  acid,  very  little  is  known. 
Indeed,  there  is  no  question  in  scientific  medicine  on 
which  we  have  fewer  facts  to  generalize  from  than  that 
concerning  the  elimination  of  "phosphates  in  disease," 
and  consequently  there  are  few  subjects  which  have 
yielded  a  richer  harvest  to  the  quack.  Physiology  can 
only  tell  us  that  the  element  phosphorus  is  absolutely 
essential  for  the  growth  and  nutrition  of  the  tissues,  but 
cannot  explain  its  role.  Whilst,  therefore,  our  informa- 
tion with  regard  to  the  physiological  action  of  phosphorus 
within  the  body  is  still  so  scanty,  it  is  obvious  we  are  not 
yet  in  a  position  to  indulge  in  speculations  concerning  the 
part  played  by  it  in  the  production  of  certain  pathological 
phenomena  with  which  it  has  been  associated.  It  is 
satisfactory,  however,  to  know  that  the  attention  of  scien- 
tific workers  has  been  called  to  this  subject,  and  we  may 
hope  that  shortly  a  sufficient  number  of  trustworthy  facts 
may  be  collected,  which  will  enable  us  to  gain  a  clearer 
insight  into  the  part  played  by  this  important  element 
with  respect  to  the  nutritive  changes  with  which  it  is  con- 
cerned within  the  body.  Nor  is  clinical  observation  in 
this  instance  much  in  advance  of  our  physiological  and 
pathological  knowledge.  Excessive  elimination  of  phos- 
phoric acid  has  been  noticed  in  acute  inflammation  of  the 
membranes  of  the  brain  (Bence  Jones),  in  the  acute 
paroxysms  of  certain  forms  of  mania  (Sutherland  and 
Beale),  and  after  injuries  to  the  head  (George  Harley). 
And  the  late  Dr.  Golding  Bird  attributed  some  of  the  cases 
of  phosphaturia  that  came  under  his  observation  to  spinal 
lesions,  probably  functional  in  character.     But  whether  in 


PHOSPHATXJEIA.  493 

these  conditions  it  is  due  to  increased  metamorphosis  of  the 
nervous  matter,  or  to  the  irritation  of  a  still  hypothetical 
"  coordinating  chemical  centre,"  or  to  the  influence  of  a 
disturbed  condition  of  the  nervous  system  upon  nutrition 
generally,  it  is  at  present  impossible  to  decide.  Increased 
elimination  of  phosphoric  acid,  again,  Beneke  has  con- 
sidered in  some  cases  to  be  due  to  excessive  formation  of 
acid  in  the  tissues,  dissolving  out  the  earthy  phosphates  ; 
in  these  cases  oxalates  and  phosphates  of  lime  will  both 
be  found  in  excess  in  the  urine.  Similarly  in  certain 
cases  of  dyspepsia  associated  with  excessive  formation  of 
lactic  acid  in  the  stomach  and  intestines,  more  phosphate 
of  Hme  may  be  rendered  soluble,  and  absorbed  into  the 
system,  and  thus  pass  out  by  the  urine  instead  of  by  the 
bowel.  Marcet  has  shown  from  analyses  of  pulmonary 
tissue  in  consumption,  that  a  considerable  reduction  of 
phosphoric  acid  and  potash  takes  place  both  in  the  in- 
soluble tissue  and  nutritive  material,  as  compared  with 
healthy  lung  tissue.  And  Edlessen  (oj^.  cit.)  has  shown 
that  the  excretion  of  phosphoric  acid  is  increased  in  cases 
of  angemia,  especially  pernicious  anaemia.  The  observa- 
tions of  the  authors  I  have  quoted  are,  however,  too 
limited  to  draw  definite  conclusions  from  as  yet.  All  that 
we  are  warranted  in  assuming  from  them  is,  that  in- 
creased excretion  of  phosphoric  acid  is  met  with  in  those 
states  of  the  system  which  we  characterise  as  "nervous," 
and  that  it  is  often  jnet  with  accompanying  or  preceding 
diseases  in  which  disorder  of  nutrition  is  usually  well 
marked,  such  as  phthisis,  diabetes,  and  cancer. 

3.  Deposit  of  ammonio  -  magnesium  johosphate  in  urine 
alkaline  from  volatile  alkali, — We  have  already  when  con- 
sidering the  variations  that  occur  in  the  reaction  of  the 
urine  in  disease  (p.  68),  described  the  nature  of  the  fer- 
mentation that  leads  to  the  decomposition  of  the  urea  in 


494  DISEASES    OF    THE    KIDKEY. 

the  urinary  passages,  and  the  formation  of  carbonate  of 
ammonia,  which  combines  with  the  magnesium  phosphate 
in  the  urine  to  form  a  triple  salt.  The  presence  of  crys- 
tals of  ammonio-magnesium  phosphate  in  urine  at  the 
time  of  its  passage  from  the  bladder  is  indicative  of  local 
(catarrhal)  disease  of  some  part  of  the  urinary  tract,  and 
not  of  constitutional  disease.  The  ferment  which  sets  up 
the  decomposition  of  the  urea  is,  in  most  cases,  introduced 
by  means  of  dirty  catheters,  but  it  may  be  introduced  by 
other  means.  Unless,  however,  according  to  the  experiments 
of  Feltz  and  Kitter,  the  ferment  be  present  in  the  urinary 
passages,  no  decomposition  of  the  urine  will  occur,  how- 
ever diseased  the  mucous  surface  may  be.  The  urines 
containing  crystals  of  the  triple  phosphate  are  generally 
alkaline,  sometimes  slightly  acid  (p.  96),  turbid  from 
mingled  pus  and  mucus,  containing  the  characteristic  pris- 
matic crystals  of  the  triple  phosphate,  whilst  phosphate 
of  lime  is  also  deposited  in  an  amorphous  form.  Some- 
times the  pus  and  mucus  combine  to  form  ropy  masses  of 
muco-pus,  which  may  be  sufficiently  bulky  as  to  obstruct 
the  flow  of  urine  from  the  bladder.  This  form  of  alkaline 
urine  is  important  from  the  part  it  plays  in  producing 
uriseptie  conditions  in  what  is  known  as  the  "  surgical 
kidney."  It  also  is  especially  characteristic  of  the  vesical 
catarrh  that  follows  on  paraplegia,  the  result  of  lesions  of 
the  spinal  cord. 

Crystals  of  triple  phosphate  occasionally  form  in  the 
urine  sometime  after  it  has  been  passed,  from  de- 
composition setting  in ;  this,  however,  has  no  pa- 
thological significance,  and  I  have  already  (p.  64)  de- 
scribed how  the  iridescent  film  occasionally  found  on 
the  surface  of  the  urine  is  caused.  Fermentation  out- 
side the  bladder,  however,  takes  place  more  readily  if  the 
urine  is  alkaline  from  fixed  alkali,  than  if  the  urine  were 


PHOSPHATUEIA. 


495 


acid  -when  passed,  consequently,  the  urines  of  those  per- 
sons who  suffer  jErom  dyspepsia,  and  pass  alkaline  urine, 
more  frequently  exhibit  the  iridescent  peUicle  than  healthy 
persons. 

Phosphate  of  lime  calculi. — Bone- earth  calculi  composed 
entirely  of  that  substance  are  rare.  They  may  be  met  with 
in  two  forms.  1.  Bounded  or  oval,  varying  in  size  from 
a  small  bean  to  a  hen's  egg,  of  white  chalky  appearance, 
with  a  very  friable  surface  and  breaking  with  an  earthy 
fracture.  2.  Irregular  in  shape,  sometimes  branched,  of 
a  greyish- white  colour,  of  compact  texture,  brittle,  and 
with  a  porcelain-hke  fracture.  The  former  are  generally 
met  with  as  vesical  calculi  in  elderly  people,  and  especially 
in  those  who  have  suffered  long  from  that  form  of  dyspep- 
sia attended  with  alkaline  urine,  due  to  the  presence  of 
fixed  alkali,  or  in  those  who  have  taken  excessive  quanti- 
ties of  alkaline  waters  or  remedies,  though  as  Dr.  Eoberts 
has  pointed  out,  that  owing  to  its  uncrystalline  condition 
bone-earth  has  very  little  tendency  to  agglomerate  into 
concretions.  A  fortunate  circumstance,  since,  if  it  were 
otherwise,  these  calculi  would  probably  be  nearly  as  fre- 
quent as  uric  acid.  The  second  variety  of  phosphate  of 
lime  calculi  is  usually  found  in  cysts  and  cavities  of  the 
urinary  organs,  and  seems  to  be  entirely  of  local  origin. 
I  have  in  my  collection  a  beautiful  specimen  of  this  form 
of  calculus,  taken  from  the  left  kidney  of  a  sailor,  who 
died  in  the  Seamen's  Hospital  from  ruptured  hver,  the 
effect  of  a  blow  from  a  capstan  bar  ;  iip  to  the  day  of  the 
injury  he  had  performed  all  his  duties  efficiently  though 
this  calculus  must  have  been  forming  for  some  years. 
The  kidney  was  completely  disorganised  and  the  calculus 
occupied  the  whole  of  the  pelvis  of  the  kidney,  and 
branched  off  to  occupy  the  cysts  in  the  body  of  that  organ, 
when  removed  it  resembled  a  mass  of  coral. 


496  DISEASES    OF    THE    KIDNEY. 

Phosphate  of  lime  sometimes  forms  alternating  layers 
with  uric  acid  this  is  specially  the  case  when  alkaline 
solvent  remedies  are  employed  to  dissolve  the  calculus, 
and  are  too  long- continued.  In  this  case  the  urine 
being  rendered  alkaline,  a  thin  deposit  of  phosphate 
of  lime  forms  on  the  surface  of  the  uric  acid  calculus, 
when  the  alkaline  remedies  are  discontinued,  uric  acid 
may  be  again  deposited  and  so  on. 

Phosphate  of  lime  associated  with  carbonate  of  Hme, 
is  deposited  in  irregular  masses  in  the  kidney,  lungs,  and 
other  organs  in  cases  of  re-absorption  of  the  bone  salts,  as 
in  osteomalacia. 

Mixed  phosphatic  calculus. — Although  calculi  composed 
entirely  of  phosphate  of  lime  are  rare,  yet  mixed  with  other 
calculous  deposits  it  is  of  tolerable  frequent  occurrence. 


Fig.  41. — Friable  crust  of  phosphate  of  lime  and  triple  phosphate. 

The  commonest  variety  is  that  composed  of  a  mixture 
of  phosphate  of  lime  and  the  triple  phosphate  of  am- 
monia and  magnesia.  It  generally  attains  a  large  size, 
is  of  a  greyish- white  colour,  very  friable  and  loose  in  tex- 
ture, breaking  off  into  thin  laminae  (fig.  41),  between 
which  the  triple  phosphate  sometimes  is  deposited  in  a 
crystalline  form.  This  concretion  is  also  known  as  the 
"  fusible  "  calculus  since  under  the  blow-pipe  it  fuses  into 
an    enamel-shaped  mass.       This    calculus    is    generally 


PHOSPHATUKIA.  497 

formed  upon  some  other  variety,  either  uric  acid  or  oxalate 
of  lime  ;  it  may  also  encrust- growths  in  the  bladder.  Its 
formation  depends  upon  the  urine  being  ammoniacal  for  a 
considerable  length  of  time,  a  condition  which  ensures  the 
precipitation  of  both  calcium  phosphate  and  ammonium- 
magnesium  phosphate.  It  may  therefore  be  regarded  as 
having  quite  a  local  origin. 

Ammo7iio -magnesium  jjJiosphate.  —  Calculi  composed  en- 
tirely of  this  salt  are  very  rare,  but  as  a  crust  or  layer  of 
other  calcuh  it  is  very  common.  Its  presence  denotes 
an  ammoniacal  condition  of  the  urine.  Its  most  frequent 
association  is  with  phosphate  of  hme,  with  which  it  is 
more  or  less  intimately  blended,  forming  the  "mixed 
phosphatic  "  or  "  fusible  "  calculus  of  which  a  descrip- 
tion has  been  given  above.  Although  rare  as  a  sole  cal- 
culous concretion  it  is  frequent  as  gravel,  when  the  urine 
is  ammoniacal,  coming  away  as  a  brownish  deposit,  partly 
crystalHne  (prisms)  and  jDartly  sub-morphous.  As  such, 
it  is  met  with  in  chronic  diseases  of  the  bladder,  after  the 
introduction  of  dirty  catheters,  or  in  urine  containing 
organisms,  sarcinse,  bacteria,  etc. 

Carbonate  of  lime  calculi  are  very  rarely  formed  in  the 
kidney,  though  it  may  sometimes  be  present  as  an  in- 


FiG.  42. — Calculus  from  prostate  gland. 

gredient  of  other  calcuH,  their  chief  seat  of  formation 
being  the  prostate  gland.  In  this  organ  two  varieties  are 
met  with  : — 1.  Of  small  size,  poppy  and  mustard  seeds,  of 
yellowish-brown  colour,  often  pyramidal  and  cubical  in 
shape,  and  their  section  marked  with  concentric  rings,  and 

KE 


498  DISEASES    OF    THE    KIDNEY. 

by  polarized  light  sometimes  displaying  a  shaded  cross  band. 
2.  Are  larger,  often  the  size  of  a  hazeL  nut,  and  have  a 
porcelain-like  appearance,  on  section  the  surface  is  found 
marked  with  radiating  stri^  (fig.  42),  these  larger  concre- 
tions are  usually  found  lodged  in  a  cyst  or  abscess  of  the 
prostate.  The  smaller  concretions  may  pass  away  with  the 
urine,  or  they  may  collect  in  the  gland,  or  as  a  rare  event 
one  may  find  its  way  into  the  bladder,  and  so  become  the 
nucleus  of  a  vesical  calculus  of  different  composition. 

Miscellaneous  cona^etions. — There  are  other  varieties  of 
urinary  concretions  such  as  fatty,  indigo,  haemic  and 
fibrinous.  The  fatty  concretions  are  composed  of  an  ad- 
mixture of  fatty  matters,  rendered  saponaceous  by  the 
alkaline  bases  of  the  urine.  This  material  is  known  by 
the  term  uro-stealith.  They  may  occur  in  large  rounded 
masses  or  as  small  rounded  concretions.  They  are,  when 
recently  removed,  soft  and  elastic,  generally  of  a  brownish 
colour  and  encrusted  with  phosphates,  in  fact  they  may 
form  the  nucleus  of  a  large  phosphatic  calculus.  The  fatty 
matter  which  forms  their  basis  is  probably  derived  from 
some  old  purulent  collection  which  has  dried  up.  Mr. 
McCarthy  {Med.  Chir.  Trans.,  vol.  Iv.)  has  given  an  account 
of  some  renal  calculi  of  unusual  shape  found  in  the  left 
kidney  of  a  woman,  who  died  of  cancer  of  the  uterus. 
These  calculi  were  accuminated,  soft  and  greasy  when  first 
removed  and  contained  36' 5  per  cent,  of  fat  and  choleste- 
rin.  In  this  case  the  medullary  portion  of  the  kidney  was 
altogether  absorbed,  and  the  cortical  substance  the  seat  of 
suppurative  nephritis.  Indigo  has  been  met  with  in  rare 
instances  both  as  a  concretion  and  as  a  deposit.  The  best 
recorded  case  is  that  by  Dr.  Ord  (Path.  Soc.  Trans.,  vol. 
xxix.).  When  it  occurs  it  is  probably  derived  from  the  in- 
dican  of  the  urine,  which  if  retained  and  acted  upon  by 
highly  acid  urine,  may  be  converted  into  indigo.   Prout  has 


ANALYSIS    OF    CALCULI.  499 

recorded  a  case  in  which  indigo  was  occasionally  voided  in 
considerable  quantity,  the  patient  was  in  the  habit  of 
taking  Seidlitz  powders,  and  the  deposit  generally  ap- 
peared in  the  urine  after  taking  one  of  these  powders. 
Fibrinous  concretions  are  of  extremely  rare  occurrence,  they 
may  be  taken  for  hardened  masses  of  uro-steaUth,  but  they 
are  insoluble  in  ether,  and  decompose  peroxide  of  hydro- 
gen, they  never  attain  a  large  size  rarely  larger  than  a 
small  pea,  rough,  uneven,  and  somewhat  resembling  bees- 
wax. They  are  probably  the  result  of  some  old  haemor- 
rhage, and  are  the  shrunken  remains  of  the  clot  that  has 
become  decolorized.  Hcemic  concretions  are  also  the  result 
of  hsematuria,  they  are  seldom  found  free,  being  usually 
encrusted  with  uric  acid  and  oxalate  of  lime,  and  then 
form  the  nucleus  of  these  calculi.  When  free  they  form 
small  rough  darkish  concretions,  extremely  light,  crushing 
with  a  cinereous  fracture  when  dry.  Examined  chemi- 
cally and  microscopically  they  show  they  are  derived  from 
blood. 

168.  Analysis  of  Calculi. — The  following  procedure 
is  the  best  adapted  for  clinical  purposes.  Note  the  size, 
colour,  and  general  appearance.  Also  whether  section 
presents  an  uniform  surface,  or  is  made  up  of  concentric 
layers.  A  portion  of  the  calculus  is  then  reduced  to  a 
fine  powder ;  if  made  up  of  several  layers  a  portion  of  each 
layer,  must  be  taken,  and  the  nucleus  examined  micro- 
scopically as  well  as  chemically. 

1.  Analysis  of  the  Common  Varieties  of  Calculi: — 

Powder  a  small  portion  of  the  calculus,  divide  the  pow- 
der into  two  portions,  and  place  one  at  one  end,  and  the 
other  at  the  other  end  of  a  glass  slide.  Label  them  respec- 
tively A  and  B. 

(A.)  Soluble  in  liquor  potasscB. — The  powder  labelled  A 
is  touched  with  a  drop  of  hquor  potassse,  by  means  of  a 

kk2 


500 


DISEASES    OF    THE   KIDNEY. 


stirring  rod.  It  dissolves  (or  only  partially  dissolves,  if 
there  are  traces  of  phosphates  or  oxalates  present),  a  drop 
of  HCl  added  to  the  alkaUne  solution  causes  a  white  pre- 
cipitate ;  indicates  uric  acid  or  urates. 


1.  Uric  acid 


2.  Urates 


3.  Cystin 


4.  Xanthin 


(Chars  under  blow-pipe  leaving  little  resi- 
due. Gives  murexide  reaction  with  nitric 
acid  and  ammonia  (p.  8). 

'  Chars  under  blow-pipe,  leaving  consider- 
able residue.  The  urates  are  soluble  in 
boiling  distilled  water,  while  uric  acid  is 
'  j  not.  Dissolve  in  boiling  distilled  water ; 
filter  and  evaporate.    The  residue  if  urates 

\^are  present  will  give  murexide  reaction. 

{Does  not  give  the  murexide  reaction. 
Boiled  with  liquor  potassse,  and  lead  acetate 
a  black  precipitate  of  lead  sulphide  is 
formed. 

f    Does  not  give  murexide  reaction  but  a 
.  j  purple  coloration,  with  nitric  acid  and  li- 
'  quor  potassae. 


(B.)  Soluble  in  hydrochloric  acid. — Touch  the  powder 
labelled  B  with  hydrochloric  acid,  it  dissolves  without 
effervescence"  (or  partially  dissolves  if  there  are  traces  of 
uric  acid).  The  acid  solution  gives  a  white  precipitate 
when  touched  with  ammonia,  and  indicates  : 

/  Chars  but  slightly  under  blow-pipe,  leaving 
friable  white  ash,  infusible.  Ash  dissolves 
without  effervescence  in  dilute  HCl.  The 
1.  Phosphate  of  lime  .-(  acid  solution  gives  a  white  gelatinous  pre- 
cipitate with  ammonium  oxalate  solution 
denoting  lime ;  also  a  precipitate  with  uran- 
ium nitrate  denoting  phosphoric  acid. 


•  If  there  is  efFervescence  it  denotes   the  presence  of  carbonate 
of  lime,  traces  of  which  are  often  found  in  phosphatic  calculi. 


ANAIiYSIS    OF    CALCULI. 


501 


2.      AmMONIO  -  MAGNESIUM 
PHOSPfliTE,    OR      TRIPLE -( 
PHOSPHATE       . 


Chars  slightly,  leaving  greyiali  ash  which 
slowly  fuses.  Soluble  in  HCl  without  effe'f- 
vescence,  from  which  excess  of  ammonia 
throws  down  a  characteristic  crystalline 
^precipitate  of  triple  phosphate  {vide  p.  96). 


3.  Phosphate 

WITH 


f  Chars  slightly,  the  ash  fuses  readily  into 
"^^  a  porcelain -like  mass ;  soluble  in  dilute  HCI 
AMMONIO  -  MAG-J  ^^^j^f^ut  effervescence.  Acid  solution  gives  a 
NESIUM  PHOSPHATE.  \  ^j^^^g  precipitate  with  ammonia,  consisting 
(Syn.  Misoed  Phosphates  Lf  ^^^^^^i^^^^  phosphate  of  lime  with  cry- 
or  fusible  calculus) .        .  I  g^^jg  ^f  ^^.^^i^  phosphate. 


4.  Oxalate  op  lime  . 


I  Chars  considerably  under  blow- pipe,  often 
with  considerable  decrepitation,  leaving  a 
white  ash  which  dissolves  with  effervescence 
in  fIGl.  A  fragment  of  the  calculus  will 
not  dissolve  in  oxalic  acid. 


2.  Eaker  Forms  of  Urinary  Calculi  : — 


1.  Dro-stealith 


2.  Fibrinous 


3.  Blood  concretions 


4.  Indigo  . 


f  Soluble  in  ether.  Will  yield  fatty  acids 
by  boiling  with  baryta  water ;  and  choles- 
terin,  if  present,  by  treating  the  etherial 
residue  with  boiling  alcohol. 

N.B.  These  calculi  often  contain  in  addi- 
tion, phosphates  or  uric  acid. 

(    Insoluble  in  ether,  the  powdered  calculus 
■  (decomposes  peroxide  of  hydrogen. 

r     Insoluble  in  ether,  test  for  hsemia  cry- 
.  \  stals.      The    ash    contains    abundance    of 
(iron. 

(Insoluble  in  ether,  soluble  in  boiling 
chloroform.  Converted  into  indigo-white 
when  boiled  with  an  alkaline  solution  of 
glucose. 


169.  Etiology.— In  speaking  of  the  origin  of  stone,  it 
was  stated  that  two  conditions   were   necessary   for   its 


502  DISEASES    OF    THE    KIDNEY. 

formation,  (a)  those  that  originated  the  nucleus,  (b)  those 
that  favoured  its  subsequent  growth.  It  no  doubt  fre- 
quently happens  that  uric  acid,  urates,  or  oxalate  of  Hme  in 
a  submorphous  condition,  and  in  a  state  fitted  to  form  the 
nucleus  of  a  calculus,  passes  into  the  urinary  passages, 
and  is  either  there  disintegrated  or  immediately  passed 
out  with  the  urine,  because  the  conditions  favouring  its 
development  are  not  present.  On  the  other  hand  we  have 
occasion  frequently  to  observe,  that  the  urine  for  long 
periods  of  time  is  often  thick  with  mucus  and  urinary  de- 
posits, a  condition  most  favourable  for  the  development  of 
stone,  and  yet  none  results,  because  in  this  instance  no 
nucleus  has  been  formed.  It  was  also  stated  that  the 
nucleus  has  its  origin  probably  in  all  cases,  certainly  in 
most,  in  the  tubules  of  the  kidney,  but  that  the  pelvis 
of  the  kidney,  and  the  bladder  are  the  seat  of  its  develop- 
ment and  growth.  In  considering  the  etiology  of  cal- 
culous affections,  our  object  will  therefore  be  to  trace  the 
action  of  certain  causes  in  bringing  about  an  alliance  of 
the  two  conditions  necessary  for  the  formation  of  stone. 

Age. — Stone  is  incontestably  more  frequent  during  the 
early  and  late  years  of  life  than  during  middle  age.  Sir 
Henry  Thompson  (o^^.  cit.)  has  shown  that  out  of  1827 
cases  operated  on  for  stone,  1158  were  under  twenty-five 
years  of  age,  1001  being  under  fifteen  years,  and  that  in 
the  thirty  years  from  twenty-five  to  fifty-five  there  were 
only  231  cases,  whilst  in  the  twenty  succeeding  years  the 
number  rose  to  303.  The  causes  that  lead  to  this  fre- 
quency of  stone  in  youth  may  be  thus  summarized ;  it 
is  a  period  when  conditions  of  "vital  impairment"  of 
the  renal  epithehum,  the  result  of  overgrowth,  sickness, 
etc.,  are  Hkely  to  be  present,  and  if  the  views  I  have  ex- 
pressed with  regard  to  the  origin  of  calculi  be  correct, 
then  such  a  condition  is  particularly  favourable  to  the 


ETIOLOGY    OF    STONE.  503 

formation  of  the  nuclei.  In  many  cases  the  nuclei  are 
undoubtedly  derived  from  the  remains  of  the  urates  de- 
posited as  infarcts  in  the  urinary  tubules  soon  after  birth, 
a  time  when  the  renal  epithelium  seems  not  to  have  ac- 
quired the  power  of  separating  the  more  solid  constituents 
from  the  concentrated  urine.  In  youth,  too,  the  retention 
and  growth  of  the  calculus  is  favoured  by  the  fact,  that 
whilst  the  nucleus  is  probably  no  smaller  than  those 
formed  in  adult  life,  the  urinary  passages  are  considerably 
smaller  and  narrower,  so  that  the  onward  passage  of  any- 
thing, save  the  very  smallest  concretion,  is  more  or  less 
hindered.  And  again,  since  it  is  during  youth  that  the 
greatest  chemical  variations  in  the  body  are  met  with,  we 
may  expect  to  find  uric  acid  generally  in  excess ;  but  what 
is  of  more  importance,  the  urine  is  often  unduly  acid  for 
long  periods,  a  circumstance  that  ensures  the  precipitation 
of  uric  acid  or  urates.  In  adult  life  the  circumstances 
favouring  the  formation  of  stone  are  less  prominent.  It 
is  a  period  of  the  greatest  functional  development  of  the 
kidney,  when  conditions  leading  to  retardation  of  the  flow 
of  urine  through  the  tubules  have  hardly  had  time  to  come 
into  play,  and  when  also  the  calibre  of  the  urinary  passages 
is  fully  developed.  In  old  age  on  the  other  hand,  we 
have  again  circumstances  favouring  the  formation  of 
nuclei,  in  the  impairment  of  the  renal  function,  as  is  shown 
by  the  senile  changes  taking  place  in  the  kidney,  whilst 
the  flow  of  urine  through  the  tubules  is  often  diminished 
by  the  obstruction  afforded  by  an  enlarged  prostate,  or  the 
effect  of  old  strictures ;  moreover,  the  expulsive  powers  are 
diminished  by  the  enfeeblement  of  the  organic  and  volun- 
tary muscles  which  aid  in  micturition. 

The  calculi  met  with  in  early  life  are  chiefly  composed  of 
uric  acid,  mingled  with  urates,  the  nucleus  almost  invari- 
ably consisting  of  the  latter  substance.     After  removal  they 


504  DISEASES    OF    THE    KIDNEY. 

rarely  recur,  if  they  do  it  is  during  the  period  of  childhood, 
a  fact  which  points  strongly  to  the  local  circumstances 
that  favour  their  formation  at  that  period,  and  a  circum- 
stance that  should  be  borne  in  mind  in  considering  the 
the  propriety  of  performing  nephrectomy  in  any  given 
case.  If  from  the  history,  we  gather  that  the  impacted 
calculus  was  formed  during  the  earlier  period  of  life,  its 
removal  may  be  determined  on  as  a  means  of  permanent 
relief;  if,  however,  the  retained  concretion  has  formed 
during  the  middle  period  of  life  or  in  old  age,  especially  in 
persons  subject  to  frequent  attacks  of  gravel,  we  have  to 
consider  whether  the  relief  afforded  is  worth  the  risk  at- 
tendant on  the  operation  since  the  condition  is  likely  to 
recur.  In  middle  life,  although  calculi  of  uric  acid  are 
still  more  frequent  than  other  varieties,  yet  this  is  the 
period  when  oxalate  of  lime  calculi  are  particularly  pre- 
valent, for  even  if  this  substance  does  not  form  the  main 
constituent  of  the  stone,  yet  it  may  almost  invariably 
be  demonstrated  as  composing  a  part  of  its  nucleus. 
Calculi  formed  at  this  period  of  life  have  a  great  tendency 
to  recur.  In  old  age,  uric  acid  calculi  numerically  retain 
the  lead,  as  they  do  at  all  other  periods  of  life,  but  the 
tendency  to  the  formation  of  oxalic  calculi  is  diminished, 
The  most  common  form  at  this  age  are  the  "  pisiform  " 
calculi  composed  of  uric  acid,  which  are  often  passed  in 
great  numbers  for  a  considerable  length  of  time.  Calculi 
composed  almost  entirely  of  phosphate  of  lime  are  more 
common  now  than  at  any  other  period  of  life  ;  whilst  the 
tendency  for  the  urine  to  become  ammoniacal  under 
conditions  of  urinary  irritation  being  more  marked,  the 
calculi  of  old  people  are  more  frequently  encrusted  with 
triple  phosphate  than  is  the  case  of  those  removed  at  an 
earlier  period. 

Climate  exercises  a  marked  influence  on  the  tendency  to 


ETIOLOGY    OF    STONE.  505 

calculus  formations.  Dividing  England  into  three  strips, 
excluding  London  on  account  of  the  number  of  patients 
sent  from  all  parts  of  the  country  for  operations,  out  of 
671  deaths  from  stone,  144  occurred  in  the  Western 
counties,  244  in  the  Midland  strip,  and  283  in  the  Eastern 
counties.  Now  when  we  come  to  consider  the  density  of 
the  population  of  the  Midlands  as  compared  with  the 
Eastern  district,  the  relative  frequency  of  stone  in  the  latter 
district  will  at  once  be  perceived,  whilst  supposing  the 
Eastern  countries  to  be  as  populous  as  the  Western,  which 
is  not  the  case,  since  the  Western  district  includes  such 
towns  as  Liverpool,  Manchester,  Bristol,  Exeter,  Plymouth, 
etc.,  then  the  mortality  from  stone  in  the  Eastern  districts 
is  twice  that  of  the  Western,  and  this  proportion  no  doubt 
would  be  increased  if  the  stone  cases  of  London  were  in- 
cluded, the  majority  of  which  are  sent  up  from  the  South 
Eastern  and  East  Anglian  districts. 

Climate  exercises  its  influence  apparently  in  three 
ways: — 1.  Meteorological  conditions.  2.  Nature  of  the 
soil.     3.  The  water  supply. 

Meteorological  conditions  act  probably  by  inducing  catar- 
rhal conditions.  In  the  Eastern  counties  the  wind  pass- 
ing over  the  fen  lands  is  rendered  cold  and  damp,  whilst 
the  East  wind,  which  is  more  prevalent  than  in  other  dis- 
tricts in  England,  often  brings  with  it  cold  raw  fogs,  which 
unlike  the  sea  fogs  of  the  West  and  South  Western  coasts, 
are  not  warmed  by  the  genial  influence  of  the  gulf  stream. 

Dry  cold  has  apparently  little  effect  in  the  production  of 
calculus.  In  Sweden,  where  in  winter  the  cold  is  intense 
but  the  air  dry,  stone  is  almost  unknown.  In  America, 
according  to  Gross,  urinary  calculi  are  rare  in  Canada,  in 
Mexico  and  California,  but  more  common  in  Ohio,  Ten- 
nessee, and  Alabama.  In  Canada  the  air  is  particularly 
dry,  as  is  the  case  in  the  mountainous  regions  of  Mexico 


506  DISEASES    OF    THE    KIDNEY. 

and  California,  whilst  the  alluvial  plains  of  the  latter 
States  are  damp  and  subject  to  frequent  floods.  Dr. 
Gross  also  states  that  stone  is  of  rare  occurrence  in  the 
coloured  races  of  America,  in  ten  years  he  never  met  an 
instance. 

The  soil  acts,  too,  in  the  same  way,  but. it  also  plays  an 
important  part  in  impregnating  the  water  with  calcareous 
salts.  In  the  purely  fen  districts  in  the  East  of  England, 
where  stone  is  very  prevalent,  the  chief  factors  no  doubt 
are  the  cold  raw  air,  and  the  sub- soil  damp  in  the  fenny 
lands ;  whilst  on  the  chalky  hills  round  Cambridge,  and 
some  parts  of  Norfolk  and  Essex,  the  hard  water  from  the 
chalk  is  the  chief  exciting  cause.  But  the  tendency  to  the 
formation  of  calculus  in  chalky  districts  is  not  altogether 
due  to  the  hardness  of  the  drinking  water,  since  chalk, 
though  it  rapidly  dries  on  the  surface,  is,  except  in  long 
periods  of  drought,  really  a  damp  soil.  To  convince  one's 
self  of  this  it  is  only  necessary  to  inspect  the  basements 
and  cellars  of  many  houses  built  on  this  formation,  and  it 
should  not  be  forgotten  that  whilst  chalk  absorbs  water, 
like  a  sponge,  it  also  retains  it.  This  circumstance  was 
originally  pointed  out  by  White  of  Selborne,  who  re- 
marked, that  on  the  huge  chalk  masses  of  the  South 
Downs,  the  little  ponds  on  the  summit  rarely  dried  up, 
even  in  the  hottest  summer,  though  fed  by  no  apparent 
spring.  This  dampness  of  a  chalk  soil  also  probably  ex- 
plains why  it  is  that  it  does  not  suit  rheumatic  patients. 
The  difference  of  soil,  too,  explains  the  reason  why  cal- 
culous affections  are  more  frequent  on  the  chalky  soil  of 
the  South  Western,  than  on  the  lime- stone  formation  of 
the  North  Western  districts ;  the  deaths  from  stone  in 
every  100,000  inhabitants,  according  to  the  Eegistrar- 
General's  returns,  being  forty-six  in  the  former,  to  thirty- 
four  in  the  latter. 


ETIOLOGY   OF    STONE.  507 

Nevertheless,  hard  water  undoubtedly  acts  as  an  impor- 
tant exciting  cause  in  cases  where  there  is  a  predisposition 
to  calculous  formations.  A  patient  of  mine,  who  for  some 
years  had  suffered  with  uric  acid  deposits,  but  who  had  never 
had  an  attack  of  gravel,  spent,  last  autumn,  a  fortnight  or 
BO  at  Brighton,  towards  the  end  of  that  period  he  had  a 
severe  attack  of  gravel  and  passed  numerous  pisiform  uric 
acid  calculi ;  he  immediately  returned  to  town,  and  since 
then  has  had  no  symptom  pointing  to  the  formation  of 
any  kind  of  renal  concretion,  though  his  urine  still  con- 
tinues to  deposit  uric  acid  crystals  whenever  his  digestion 
is  deranged.  Another  patient,  permanently  resident  at 
Brighton,  has  suffered  from  the  passage  of  small  stones 
for  years,  on  my  recommendation  he  uses  now  only  dis- 
tilled water,  and  he  tells  me  that  so  long  as  he  employs  it 
he  is  free  from  colic,  but  should  he  by  any  chance  be 
driven  to  use  the  Brighton  water  for  a  few  days,  he  is  sure 
to  pass  a  small  stone  shortly  afterwards.  In  both  these 
cases  I  think  the  attacks  may  fairly  be  attributed  to  the 
hard  water,  the  lime  forming  an  insoluble  urate,  and  also 
probably  an  oxalate,  since  both  urates  and  oxalates  are 
generally  found  composing  the  nuclei  of  the  calculi  of 
persons  who  have  resided  in  chalky  districts.  Whilst  on 
this  point,  it  is  interesting  to  observe  that  horses  and 
cattle  instinctively  prefer  soft  to  hard  water,  and  they  will 
turn  from  a  bucket  of  clear  spring  water  to  the  muddy 
and  polluted,  but  soft,  water  of  the  horse  pond.  Now,  in 
these  animals,  the  urine  is  almost  entirely  deficient  in 
phosphoric  acid  and  lime  salts,  a  fortunate  circumstance, 
since  as  their  urine  is  alkaline,  they  escape  the  risks  of 
the  deposition  of  phosphate  of  lime.  Their  preference  for 
soft  water  may  be,  therefore,  explained  by  some  instinc- 
tive taste  which  leads  them  to  select  the  fluid  best  suited 
for   their  requirements.      Parkes  has  told  us  that  with 


508  DISEASES    OF    THE    KIDNEY. 

horses  the  change  from  soft  to  hard  water  causes  indiges- 
tion, loss  of  condition,  and  roughness  of  coat.  Whilst  a 
practical  grazier  has  informed  me  that  calculous  com- 
plaints are  rare  among  cattle  kept  in  the  fields  where  they 
drink  chiefly  the  rain-water  from  ponds  and  ditches,  whilst 
cattle  brought  up  in  the  farm-yard,  as  bulls  and  stock 
for  market,  and  where  the  water-supply  is  taken  from  the 
well,  are  not  infrequently  attacked. 

Sex. — Owing  to  the  shortness  and  less  complex  nature 
of  the  female  urethra,  and  its  greater  dilatability,  vesi- 
cal calculi  are  much  rarer  among  females  than  males. 
Females,  too,  are  less  liable  to  renal  concretions  than 
men,  though  not  nearly  so  much  so,  as  in  the  case  of  vesi- 
cal calculi ;  this,  no  doubt,  is  owing  to  their  being  less 
exposed  to  the  other  predisposing  causes,  about  to  be 
enumerated,  than  the  male  sex. 

General  causes. — An  highly  animalized  diet  and  the  im- 
moderate use  of  certain  alcoholic  beverages,  powerfully 
predispose  to  the  formation  of  stone  and  gravel.  This  no 
doubt  was,  with  the  inefficient  drainage  of  the  land,  an 
important  factor  in  causing  the  prevalence  of  these  com- 
plaints in  the  last  century,  when  all  who  could  afford  it, 
washed  down  the  substantial  roast  and  boiled  with  strong 
ales,  whilst  port  wine,  Madeira,  and  rich  brown  sherries, 
were  also  largely  consumed.  Now,  with  the  introduction 
of  a  lighter  cuisine,  mild  bitter  ales,  cheap  claret,  and  a 
better  drained  sub- soil,  each  decennium  shows  a  marked 
diminution  in  the  mortality  from  these  complaints.  The 
employment  of  a  highly  nitrogenous  diet,  and  the  im- 
moderate use  of  saccharine  alcohohc  drinks,  undoubtedly 
induce  a  tendency  to  stone,  by  causing  indigestion,  acidity 
from  fermentation,  and  malassimilation  ;  but  their  most 
important  eifect  in  this  particular,  is  brought  about  by  the 
increased  metamorphosis  and  waste  of  tissue  which  they 


EENAL    COLIC.  509 

cause.  In  this  way  the  nitrogenous  excretion  through 
the  kidney  is  greatly  increased,  so  that  impairment  of  the 
functional  activity  of  the  renal  cells  is  at  last  induced, 
and  such  insoluble  substances  as  urates  and  oxalates  in- 
stead of  being  eliminated  by  them,  may  at  length  come  to 
be  retained  Sedentary  habits  also  favour  the  production 
of  stone  and  gravel.  The  skin  fails  to  discharge  ade- 
quately its  depurating  function,  especially  as  regards  the 
elimination  of  free  acid  from  the  body,  whilst  the  pul- 
monary exhalation  of  carbonic  acid  is  not  vigorously  per- 
formed. The  consequence  of  this  retention  of  acid  is, 
that  the  alkalinity  of  the  blood  is  lessened,  and  in  order 
to  restore  the  balance,  more  than  the  normal  quantity 
of  acid  has  to  be  removed  by  the  urine.  This  constant 
discharge  of  an  highly  acid  urine  may  impair  the  vitality 
of  the  renal  epithelium,  whilst  it  certainly  ensures  the 
precipitation  of  the  insoluble  uric  acid  and  urates. 

170.  Symptoms. — The  symptoms  of  renal  calculus 
arise  from  the  effects  caused  by  its  presence  in  the  pelvis 
of  the  kidney.  Pain,  irritation  of  the  mucous  surfaces 
(pyelitis),  hgematuria,  and  retraction  of  the  testicle  are 
the  most  prominent.  In  some  cases  there  is  more  or 
less  gastric  disturbance  and  reflex  vomiting. 

Reyial  colic,  or  nephalgia,  is  the  pain  excited  by  the 
presence  of  a  foreign  body  in  the  pelvis  of  the  kid- 
ney. This  pain  may  be  slight  so  long  as  the  irritant 
is  quiescent,  but  if  it  is  moved,  or  pressed  onwards 
into  the  ureter,  the  pain  becoines  excessive.  Thus  it 
happens  that  a  small  calculus  is  generally  attended  with 
infinitely  more  pain  than  a  large  one.  For  a  calculus 
large  enough  to  fill  the  whole  pelvis  is  more  or  less  firmly 
fixed,  and  consequently  beyond  the  dragging  sensation 
caused  by  its  weight,  pain  is  little  felt.  Even  a  moderate 
sized  calculus  which  does  not  occupy  anything  like  the 


510  DISEASES    OF    THE    KIDNEY. 

whole  of  the  pelvis  may  exist  for  a  long  time  without 
exciting  urgent  pain,  since  in  this  case  it  may  become  par- 
tially encysted  in  a  pouch  of  the  pelvis,  from  which  it  is 
not  easily  dislodged,  except  after  severe  jolting,  etc.  But 
a  small  calculus  rarely  gets  fixed,  and  every  movement  of 
the  body  acts  upon  it,  and  sets  it  moving,  besides  which 
the  natural  expulsive  efforts  are  always  tending  to  force  it 
towards  the  ureters,  so  that  at  last  the  patient  is  quite 
worn  out  with  the  attacks  of  pain.  From  the  dull  aching 
pain  caused  by  the  weight  of  a  large  renal  calculus  to  the 
agonizing  cohc  attendant  on  the  passage  of  a  small  stone 
from  the  pelvis  of  the  kidney  down  the  ureter,  there  are 
infinite  gradations,  but  the  character  is  similar  through- 
out. The  onset,  or  the  aggravation,  of  the  pain  is  sudden, 
generally  brought  about  by  some  movement  of  the  patient. 
The  pain  is  referred  to  the  loins,  springing  forwards,  and 
sometimes  radiating  upwards  to  the  chest,  so  that  one  is 
led  to  suppose  the  patient  may  be  suffering  from  pleurisy, 
more  generally  downwards  causing  exquisite  pain  along 
the  cord  and  testicle  of  the  side  affected,  which  is  strongly 
retracted  against  the  pubes,  the  latter  organ  being  slightly 
swelled  and  exquisitely  tender  to  the  touch.  The  patient 
rolls  over  and  over  in  his  agony,  keeping  his  thighs  tightly 
flexed  over  his  abdomen,  and  resting  on  the  affected  side. 
The  pain  at  the  onset  may  be  so  severe  as  to  cause  faint- 
ing, in  severe  attacks  there  is  always  vomiting.  The  pain 
is  paroxysmal ;  even  in  a  continued  paroxysm,  one  can 
usually  observe  short  lulls  quickly  followed  by  exacerba- 
tions. This  severe  pain  lasts  during  the  whole  of  the  pas- 
sage of  the  stone  from  the  kidney  to  the  bladder,  when  it 
suddenly  ceases.  If  the  stone  does  not  pass,  the  colic 
usually  subsides  after  four  or  five  hours  duration,  to  renew 
itself  very  shortly  if  no  rehef  has  been  given  by  remedies, 
but  fortunately  in  the  majority  of  cases,  the  rest  and  the 


EENAX.    COLCC.  511 

medicinal  treatment  tliat  follow  such  an  attack,  are  suffi- 
cient to  ensure  against  an  immediate  return,  till  some 
fresh  movement  disturbs  the  stone  again.  Short  of  these 
attacks  of  severe  pain,  there  may  be,  generally  in  the  in- 
terval, but  often  as  the  only  attendant  manifestation, 
reflected  pain  ;  this  may  present  itself  in  the  testicle,  and 
may  be  mistaken  for  neuralgia  of  that  organ,  or  it  may 
manifest  itself  in  painful  irritability  of  the  bladder,  so 
that  we  may  be  led  to  fancy  that  the  stone  is  forming  there 
whilst  it  is  still  in  the  kidney,  by  no  means  an  uncommon 
mistake,  or  by  a  numb  sensation  down  the  thighs  ;  or 
a  burning  pain  may  be  constantly  present  in  one  of  the 
heels,  the  sole  of  the  foot,  or  more  rarely  the  outside  edge 
of  the  foot,  running  along  the  border  towards  the  httle  toe. 
As  these  reflected  pains  are  paroxysmal,  and  often  accom- 
panied with  reflex  vomiting,  they  are  sometimes  regarded 
as  dependent  upon  disease  of  the  spinal  cord.  Thus,  an 
American  gentleman,  who  for  years  had  suffered  from 
paroxysmal  attacks  of  violent  pain  on  the  outer  side  of 
the  left  foot  and  ankle,  and  who  had  consulted  most  of 
the  leading  neurologists  in  Europe,  was  kept  in  Paris 
six  weeks,  with  ice  bags  more  or  less  constantly  ap- 
plied to  the  spine  for  supposed  congestion  of  the  spinal 
cord,  came  under  my  observation  in  1878,  when  he  was 
suffering  from  a  very  severe  paroxysm.  Closely  ques- 
tioning him  with  regard  to  his  past  history  I  learnt  he  had 
passed  bloody  urine  about  five  years  before,  or  about  six 
months  before  the  commencement  of  the  paroxysms.  I 
regarded  the  case  as  one  of  nephro-lithiasis,  and  abandon- 
ing the  galvanism,  the  electric  baths,  blisters  to  the  spine, 
heated  irons,  etc.,  with  which  for  five  years  he  had  been 
tormented,  advised  him  to  take  a  course  of  Carlsbad  water, 
to  diminish  the  amount  of  nitrogenous  food,  and  keep  his 
urine  neutral.      Since  then  he  has  improved  considerably, 


612  DISEASES    OF    THE    KIDNEY. 

the  paroxysms  are  much  less  severe,  and  do  not  occur  un- 
less he  commits  some  imprudence  ■with  regard  to  diet,  or 
the  urine  becomes  unduly  acid,  whilst  his  general  health 
is  decidedly  better.  In  another  case,  a  gentleman  who  con- 
sulted me  for  some  stomach  derangement,  told  me  that 
three  years  previously  he  had  suffered  from  paroxysmal 
lumbar  and  sciatic  pains  often  accompanied  with  retching. 
An  eminent  surgeon  had  told  him  his  symptoms  pointed, 
to  an  early  stage  of  locomotor  ataxy,  whilst  a  physician 
had  told  him  they  were  the  result  of  syphilitic  disease 
of  the  cord,  and  gave  him  small  doses  of  mercury  for 
nearly  a  year.  By  some  chance  he  happened  to  con- 
sult another  surgeon,  and  shortly  afterwards,  under  that 
gentleman's  treatment  passed  a  small  oxalate  of  Hme 
calculus,  which  relieved  him  of  those  symptoms.  Such 
cases  should  impress  upon  us  the  importance  of  examining  the 
urine  immediately  after  any  attack  of  paroxysmal  pain  occur- 
ing  in  the  lower  extremities,  even  in  the  absence  of  any  pain 
over  the  region  of  the  kidneys  themselves;  especially  with 
regard  to  the  detection  of  pus  cells,  blood  corpuscles,  and 
the  nature  of  the  crystalline  deposit. 

Pyelitis. — The  irritation  produced  by  the  presence  of 
a  renal  concretion  in  the  pelvis  of  the  kidney  soon  sets 
up  inflammation  of  the  mucous  surface,  so  that  pus  is 
always  found  as  one  of  the  earliest  results  of  calculous 
formation.  The  degree  of  pyelitis  thus  set  up  depends 
very  much  on  the  form  and  nature  of  the  calculus.  If 
smooth  and  rounded,  like  most  of  the  uric  acid  calculi,  and 
of  sufficient  size,  so  as  to  fill  a  pouch  in  the  pelvis  of  the 
kidney,  then  little  disturbance  is  caused,  but  if  as  is  some- 
times the  case,  these  renal  concretions  have  a  spiny  pro- 
jection, or,  as  in  the  oxalate  of  lime  calculus,  the  surface  is 
rough  and  angular,  then  the  irritation  will  be  considerable, 
and  the  amount  of  pus  formed  and  discharged  abundant. 


SYMPTOMS  OF  EENAL  CALCULUS.  513 

Should  the  calculus  ohstruct  the  opening  into  the  ureter, 
the  flow  of  pus  will  be  arrested,  and  an  accumulation  take 
place  in  the  pelvis,  this  may  be  discharged  intermittently 
as  the  calculus  shifts  its  position,  or  it  may  form  a  per- 
manent accumulation  (pyo-nephrosis)  if  the  calculus  is 
impacted. 

HcEmaturia. — Blood  corpuscles  are  not  so  invariably 
present  as  pus  cells  in  cases  of  renal  concretion,  still  they 
will  be  found  after  every  exacerbation  of  pain,  if  the  urine 
be  examined  immediately  after  the  attack.  Sometimes  the 
amount  of  blood  passed  is  considerable,  tinging  the  urine 
a  deep  red,  and  sometimes,  though  rarely,  in  sufficient 
quantities  to  form  coagula,  which  pass  with  great  difficulty 
down  the  ureters  to  the  bladder.  The  tendency  to  haemor- 
rhage is  aggravated  by  exercise,  especially  jolting  move- 
ments. It  has  been  well  said  that  a  man  with  a  stone  in 
his  kidney  may  walk  but  cannot  drive ;  whilst  a  man  with  a 
stone  in  his  bladder,  often  cannot  take  walking  exercise, 
but  may  ride  comfortably  in  his  carriage.  In  the  hsema- 
turia  from  the  kidney,  the  urine  generally  maintains  its 
acid  reaction,  and  the  first  portion  is  as  highly  coloured  as 
the  last,  whilst  in  vesical  hsematuria  the  urine  is  often 
alkaline,  thick,  and  muco-purulent,  and  the  last  portion  of 
the  urine  often  appears  more  bloody  than  when  the  stream 
commenced,  indeed  the  last  drops  are  often  pure  blood,  as 
in  the  case  of  fungoid  disease  of  the  bladder. 

Gastric  disturbances. — The  reflex  vomiting  that  so  fre- 
quently occurs  during  renal  colic,  in  no  way  differs  from 
that  occasioned  by  disturbance  in  other  organs.  The 
onset  of  the  pain  and  the  act  of  vomiting  may  be  almost 
simultaneous,  at  first  the  food,  if  any  is  in  the  stomach,  is 
ejected,  then  an  acid  glairy  fluid,  mucus  and  acid  gastric 
juice,  which  finally  after  repeated  vomiting  becomes 
coloured  with  bile. 

LL 


514  DISEASES    OF    THE    KIDNEY. 

Retraction  of  the  testicle. — In  all  cases  of  renal  concre- 
tion, I  have  found  this  symptom  invariably  present.  Oc- 
casionally it  may  give  a  clue  in  an  obscure  case,  thus  I 
was  not  long  since  called  to  see  a  gentleman,  a  stranger  to 
myself,  who  whilst  at  breakfast  suddenly  complained  of 
intense  pain  in  the  abdomen,  vomited  his  food  and  then 
fainted.  From  what  I  heard,  I  thought  probably  there 
had  been  a  rupture  of  an  abdominal  or  iliac  aneurism. 
On  arriving,  I  therefore  at  once  examined  the  abdomen, 
when  I  noticed  the  right  testicle  strongly  retracted,  which 
made  me  suspect  the  probable  nature  of  the  attack,  and 
quiet  the  apprehension  of  his  friends.  The  patient  soon 
began  to  rally,  was  again  violently  sick,  but  had  no  com- 
plaint of  pain  anywhere,  when  suddenly  he  called  for  a 
chamber  vessel,  and  then  with  great  urgency  passed  a  few 
drops  of  bloody  urine,  which  confirmed  the  opinion  I  had 
drawn  from  the  retracted  testicle,  and  later  in  the  day  he 
X^assed  pei-  iirethram  a  small  uric  acid  calculi. 

171.  Diagnosis. — An  attentive  examination  of  the 
urine  from  day  to  day  would  preclude  the  possibility  of 
overlooking  the  existence  of  a  renal  calculus,  even  if  other 
symptoms  were  not  pronounced.  A  difficulty  certainly 
arises  sometimes  in  those  cases,  as  in  cancer  of  the  kidney, 
or  scrofulous  disease  of  the  kidney,  in  which  masses  of 
softened  cancerous  or  tuberculous  matter  are  detached  and 
passed  down  the  ureters,  giving  rise  to  colic,  accompanied 
with  bloody  urine.  A  careful  examination  of  the  urine, 
however,  especially  of  the  detritus,  and  the  clinical  circum- 
stances of  the  case,  generally  enable  us  to  arrive  at  a  con- 
clusion without  much  difficulty  (see  Cancer  and  Scrofulous 
kidney).  A  rapidly  growing  renal  calculus,  such  as  those 
composed  of  triple  phosphate  and  phosphate  of  lime,  or 
large  oxalate  of  lime  concretions,  by  causing  a  tumour  in 
the  loin,  may  be  taken  for  cancer,  the  following  points, 


SYMPTOMS  OF  RENAL  CALCULUS.  515 

however,  will  serve  us  to  discriminate  between  the  two. 
In  cancer,  the  amount  of  blood  is  generally  more  consider- 
able than  with  calculus,  and  occurs  often  independently  of 
unwonted  exertion.     Small  red-coloured  gelatinous  look- 
ing lumps  may  sometimes  be  observed  in  the  urine  after 
attacks    of  hsematuria   in   cancer.     Examination   of  the 
urine  may  show  cancer  cells   if  fragments  come  away ; 
if  this  sign  is  absent,   then   the   character   of  the   urin- 
ary   deposit   may   help    us ;    in   cancer,   it   has   often   a 
mashy  appearance,   and  is   more   free   from  pus,  mucus 
and   crystaUine   deposit,    than   that  caused   by   calculus. 
In   cancer,    nausea    occurs    frequently  independently   of 
pain  or  haemorrhage,   in  renal  calculus  it  is  not   gene- 
rally observed  except  during  attacks  of  colic.     It  should, 
however,  be  borne  in  mind  that  cancer  may  be  secon- 
dary to   long-standing    calculus    disease   of  the    kidney, 
though  this  contingency  is  not  nearly  so  frequently  ob- 
served as  with  gall  stones.     Nor  should  the  fact  be  over- 
looked that  irritation  of  the  kidney  may  exist  without  there 
being  any  symptom  referrable  to  that  organ,  whilst  the 
pain  and  irritabihty  of  the  bladder  may  lead  one  to  sup- 
pose that  viscus  is  affected,   and  vice  versa.     Thus  in  the 
case  of  an  old  lady,  I  used  sometimes  to  see,  in  whose  left 
kidney  was  lodged  an  enormous  calculus,  all  her  trouble, 
was  referred  to   the  bladder,  and  nothing  could  convince 
her  that  she  had  no  stone  in  that  organ,  though  she  was 
sounded,   with  no  result,  by   Sir  Henry  Thompson  and 
Sh  Prescott  Hewett.     In  another  case,  the  reverse  of  the 
one  just  quoted,  in  which  an  abscess  opened  into  the  base 
of  the  bladder,  all  the  symptoms  pointed  for  many  weeks 
to  pyelitis  of  the  right  kidney,  and  it  was  not  till  I  asked 
Mr.  John  Wood  to  examine  the  bladder  for  me  with  a 
sound,  thinking  from  a  change  of  symptoms  that  a  stone 
had  passed  from  the  kidney  to  the  bladder,  that  the  real 

ll2 


516  DISEASES    OF    THE    KIDNEY, 

nature  of  the  lesion  was  determined.  In  tliese  doubtful 
cases  a  careful  examination  of  the  bladder  should  always 
be  resorted  to. 

In  undertaking  the  treatment  of  stone,  it  is  of  course  of 
importance  to  diagnose  the  leading  chemical  characteristic 
of  the  calculus  deposit.  For  medical  reasons,  in  order  to 
select  the  appropriate  remedy ;  and  for  surgical,  as  to  its 
probable  hardness  and  power  of  resistance  to  the  lithotrite, 
and  also  its  tendency  to  recur.  In  order  to  come  to  a  conclu- 
sion on  this  point,  every  detail  concerning  the  past  urinary 
history  of  the  case  should  be  carefully  reviewed.  The  pre- 
vailing character  of  the  crystaUine  deposits  at  an  early  stage, 
the  subsequent  variations  in  the  reaction  of  the  urine,  and 
the  nature  of  the  crystalhne  dex30sit  at  the  present  time, 
the  amount  and  character  of  the  haemorrhage,  will  aid  us  in 
coming  to  a  right  conclusion.  Thus  if  we  have  a  history 
of  long  continued  uric  acid  deposit,  which  has  nearly  ceased 
for  some  time,  if  the  reaction  be  acid,  and  much  mucus  is  dif- 
fused through  the  urine,  that  in  addition  to  the  hsematuria, 
which  though  frequent  is  never  excessive,  caused  by  exer- 
cise, there  is  also  a  periodic  haemorrhage  apt  to  occur  at 
tolerably  regular  intervals  independently  of  exertion,  and 
the  mucous  deposit  in  the  urine  has  a  yellowish,  or 
rusty  tinge,  then  we  may  assume  that  the  concretion  is 
composed  of  uric  acid.  If  on  the  other  hand  the  patient 
has  suffered  from  oxaluria,  or  we  have  the  history  of  a 
dyspepsia  attended  with  great  mental  depression,  and  the 
urine  though  acid  is  not  so  to  a  very  high  degree,  whilst  the 
haemorrhage  is  abundant  and  very  dark  coloured,  and  the 
mucous  deposit,  when  blood  is  absent,  is  of  a  glairy  green- 
ish colour,  then  an  oxalate  of  Ume  concretion  may  be  sus- 
pected. With  phosphatic  calcuh,  there  is  the  history  of 
long  continued  alkahnity  of  the  urine,  either  fixed  or  vola- 
tile, or  both  ;  whilst  the  urine   either  contains  abundance 


TKEATMENT  OF  KENAL  CALCULUS. 


517 


of  muco-pus,  or  else  an  abundant  flocculent  precipitate 
of  mucus,  whilst  decided  hasmorrhage  is  a  rare  event,  yet 
the  urine  and  mucus  are  generally  tinged  with  blood. 

172.  Treatment.— A  renal  calculus  may  pass  down- 
wards from  the  kidney  to  the  bladder,  and  then  if  prompt 
treatment  be  adopted,  it  may  whilst  still  small,  pass  out 
■per  urethram.  If  this  fortunate  event  is  not  accomplished, 
it  remains  in  the  bladder  and  developes  into  a  vesical 
calculus.  Or  the  stone  may  be  retained  in  the  kidney,  in 
which  case  it  may  become  impacted  and  gradually  enlarge 
without  giving  rise  to  much  trouble,  or  it  may  remain 
loose  in  the  pelvis  of  the  kidney,  setting  up  a  degree  of 
pyelitis  which  either  induces  renal  abscess  and  peri-neph- 
ritis, and  then  leads  to  the  discharge  of  the  stone  by  means 
of  a  fistulous  opening  in  the  abdominal  walls,  or  surgical 
means  have  to  be  employed  for  its  removal.  Our  treat- 
ment, therefore,  has  to  be  adapted  to  these  various  circum- 
stances, and  we  have  now  to  consider  seriatim  the  means 
to  be  employed  during  the  passage  of  the  stone  down  the 
ureters,  for  its  early  removal  from  the  bladder,  for  its 
relief  should  it  be  retained  in  the  kidney,  and  the 
measures  to  be  adopted  to  prevent  recurrence  after  it  has 
been  removed  either  by  medical  or  surgical  means. 

Treatment  of  renal  colic— Over  efforts  must  be  directed 
towards  the  reHef  of  pain,  and  facilitating  the  passage  of 
the  stone  down  the  ureter.  The  first  step  to  be  taken  is 
to  ensure  the  thorough  evacuation  of  the  bowels.  Not 
only  does  a  loaded  condition  of  the  bowels  in  itself  act  as 
a  hindrance  to  the  passage  of  the  stone,  but  owing  to  the 
relation  of  the  large  intestine  to  the  anterior  surface  of 
the  kidney,  considerable  pain  is  caused  by  its  pressure  on 
the  tender  organ.  The  act,  too,  of  emptying  the  bowel 
also  aids  the  expulsive  efforts  directed  towards  forcing  the 
concretion  down  the  ureter ;    in  the  case  of  small  calculi 


518  DISEASES   OP    THE    KIDNEY. 

I  have  known  immediate  relief  to  follow  a  copious  evacua- 
tion of  the  bowel.  The  best  means  to  effect  this  is  by 
enemata  of  warm  water,  followed  by  the  injection  of  olive 
oil,  if  there  is  reason  to  think  the  faeces  are  hardened  or 
scybalous.  Even  if  the  bowels  are  not  loaded,  an  enema 
is  of  service  for  the  relief  of  the  flatulent  distension  which 
is  usually  very  great  in  these  cases.  As  soon  as  the 
bowels  are  relieved  the  patient  should  be  placed  in  a  hot 
bath  of  98°  F.,  gradually  raised  to  100°  F.,  for  twenty 
to  thirty  minutes.  On  leaving  the  bath,  a  full  dose  of  solid 
opium,  if  there  is  no  chronic  renal  disease  to  contra- 
indicate  its  administration,  should  be  given,  and  gentle 
but  firm  shampooing  in  a  direction  downwards  from  the 
loin  towards  the  groin,  frequently  applied.  During  the 
paroxysm  of  severe  pain,  chloroform  may,  from  time  to 
time,  be  administered ;  it  not  only  subdues  the  pain,  but 
also  by  reUeving  spasm  facilitates  the  escape  of  the  stone. 
The  patient  should  also  be  encouraged  to  drink  copiously  of 
barley-water,  or  better  still  if  it  is  handy,  of  distilled  or  soft 
water.  After  the  continuance  of  some  hours,  the  colic 
will  abate,  somewhat  suddenly  if  the  stone  has  passed  into 
the  bladder,  more  gradually  if  it  is  still  retained  in  the 
pelvis  or  the  ureter.  If  the  latter  is  the  case,  we  must 
ensure  the  patient  a  period  of  rest  after  his  severe  suffer- 
ing, by  placing  him  in  a  comfortable  position  in  bed, 
which  is  generally  effected  by  letting  him  lie  on  the  side 
affected  with  his  thighs  well  flexed,  and  by  giving  him  a 
morphia  injection,  sufficiently  strong  to  secure  some  hours 
of  sleep,  if  the  dose  of  opium  first  given  is  not  sufficient 
for  the  purpose.  The  subsequent  treatment  is  deter- 
mined by  the  course  of  events.  Should  the  concretion, 
however,  fortunately  have  passed  into  the  bladder,  we 
must  proceed  at  once  to  take  measures  for  its  expulsion 
from  that  cavity  before  it  has  time  to  increase  its  bulk. 


TREATMENT  OF  EENAL  CALCULUS.  519 

The  renal  concretion  has  j^assed  into  the  bladder. — A  calculus 
that  lias  just  passed  down  a  ureter,  is  certainly  not  too 
large  to  pass  through  the  adult  urethra,  always  supposing 
no  stricture  or  prostatic  enlargement  is  present.  To 
secure  its  early  expulsion  it  is  often  sufficient  to  dkect  the 
patient  to  retain  his  urine  till  the  bladder  is  full,  and  then 
gently  compressing  the  orifice  of  the  urethra  with  the 
thumb  and  finger,  to  make  a  strong  expulsive  effort  to 
micturate,  then  suddenly  to  release  the  pressure  at  the 
orifice,  and  half  empty  his  bladder,  then  again  to  com- 
press the  urethra,  and  again  release  the  stream  till  the 
bladder  is  emptied.  In  this  way  the  concretion  is  carried 
by  the  strong  stream  outwards  towards  the  urethra,  and 
may  thus  happily  be  discharged.  It  often  happens,  how- 
ever, that  the  patient  feels  the  stone  carried  to  the  en- 
trance of  the  urethra  and  then  feels  it  fall  back  again,  this 
is  generally  the  case  with  long  oval-shaped  concretions 
which  have  passed  with  their  long  axis  downwards  through 
the  ureter,  but  present  themselves  transversely  at  the 
entrance  of  the  urethra.  In  this  case,  the  patient  should 
be  encouraged  to  persevere  in  fiUing  and  emptying  his 
bladder,  as  we  hope  that  on  one  such  an  attempt,  a  pre- 
sentation favourable  for  its  outward  passage  may  occur. 
In  cases  were  there  is  atony  of  the  bladder,  it  is  a  good 
plan  to  introduce  a  full- sized  catheter,  half  empty  the 
bladder,  then  withdraw  the  instrument,  when  the  stone 
will  very  frequently  follow  after  the  catheter  into  the 
urethra.  The  concretion  in  passing  down  the  urethra, 
may  give  rise  to  much  pain,  especially  if  its  surface  is 
rough  or  irregular.  It  may  also  become  fixed,  but  in  most 
cases  the  pressure  of  urine  from  behind  it,  is  sufficient  to 
force  it  on,  or  if  in  the  anterior  portion  of  the  urethra,  it 
may  be  squeezed  forward  by  the  fingers  ;  but  if  it  does  not 
pass   it   must   be   removed  by  surgical  means.      Should 


520 


DISEASES    OF    THE    KIDNEY. 


these  attempts  fail  to  remove  the  stone  from  the  bladder, 
it  is  worth  while  employing  the  use  of  solvents,  since  it  is 
in  these  early  cases  of  vesical  calcuH  that  their  action  is 
most  marked.  This  mode  of  treatment  wiU  be  described 
in  the  next  paragraph,  where  we  speak  of  the  solvent 
treatment  of  renal  calculi. 

The  calculus  7'emains  in  the  pelvis  of  the  kidney. — In  this 
case  the  cohc  is  either  frequently  repeated,  or  else  after  a 
certain  period  of  more  or  less  pain  and  discomfort,  the 
symptoms  gradually  subside,  owing  to  the  calculus  be- 
coming encysted.  Our  treatment,  therefore,  will  be 
guided  by  these  natural  indications.  If  there  should  be 
frequent  attacks  of  colic,  we  ought  in  the  first  instance 
to  endeavour  to  effect  the  passage  by  trying  to  diminish 
the  bulk  of  the  calculus  by  means  of  solvents,  and  also 
to  render  the  urinary  passages  more  favourable  to  its 
passage  by  diminishing  the  catarrh.  Solvent  remedies 
were  much  in  vogue  during  the  century  before  the 
introduction  of  chloroform  and  the  employment  of  litho- 
trity,  and  considerable  success  no  doubt  attended  their 
employment,  and  in  spite  of  Sir  Henry  Thompson's 
statement,  that  he  cannot  find  that  any  patient  certified 
to  have  stone,  after  sounding  by  a  competent  surgeon, 
after  a  course  of  any  solvent  was  subsequently  found  free 
from  stone  ;  four  cases  are  reported  (Tracts  B,  No.  4,  250 
Library  Royal  Med.  Chir.  Soc.)  in  which  stones  were  de- 
tected by  Mr.  Nourse  of  St.  Bartholomew's,  Mr.  Sharp  of 
Guy's  Hospital,  and  Mr.  Cheselden  of  St.  George's  Hospi- 
tal, by  sounding,  and  the  patients  after  a  course  of  solvents, 
during  which  a  large  quantity  of  grit  was  passed,  were 
found  by  the  same  surgeons,  on  again  sounding,  to  be  free 
from  stone.  To  these  may  be  added  the  well  authenticated 
cases  of  Dr.  Jurin  and  Dr.  Whytt,  whilst  besides  these  I 
have  collected  from   various  sources  some  130  cases  in 


TREATMENT  OF  RENAL  CALCULUS.  521 

which  the  use  of  solvent  remedies  was  followed  by  either 
complete  relief,  or  diminution  of  suffering.     The  solvent 
remedies  employed  in  those  days  were  either  solutions  of 
soap,  hme-water,  or  else  strong  infusions  of  wood  ashes. 
In  this  form  though  they  rendered  the  urine  powerfully 
alkaHne,  they  had  the  disadvantage   of  disordering  the 
stomach,  and  were  by  no  means  so  perfect  or  so  easily 
applied  as  the  remedies  now  a,t  our  command.      In  con- 
sidering the  efficacy  of  the  solvent  treatment   we   must 
bear  in  mind  one  important  fact,  and  that  is,  it  is  better 
suited  for  the  solution  of  vesical  than  renal  calculi.      The 
reason  of  this  is,  that  the  urinary  bladder  is  capable  of 
holding  three  or  four  ounces  of  alkaline  fluid,  which  can 
be  retained  for  some  hours,  and  which  thus  completely 
surrounds  the  stone,  whilst  in  the  kidney  the  urine  in  con- 
tact with  the  stone  at  any  given  time,  is  only  small  in 
quantity,  and  as  it  passes  away  directly  to  the  bladder^ 
it  is   therefore   much  more   difficult   to  keep   the   urine 
constantly  alkaline,  a  greater  quantity  of  alkali  having  to 
be  administered.      The  solvent  treatment  is  therefore  best 
adapted  for  the  solution  of  smaU  calculi  just  passed  into 
the  bladder.     The  treatment  is  carried  out  as  follows  :  the 
patient  having  emptied  his  bladder,  twenty  to  thirty  drops 
of  liquor  potassse,  or  forty  to  sixty  grains  of  citrate  of 
potash  as  recommended  by  Dr.  Eoberts,  should  be  ad- 
ministered in  some  bitter  infusion,  every  four  hours,  in 
the  meantime  the  patient  is  to  drink  as  little  water  as 
possible,  so  that  the  urine  should  be  concentrated  and  the 
degree  of  alkalescence  kept  as  high  as  possible,  whilst  he 
should  be  directed  to  retain  his  urine  as  long  as  he  can, 
so  that  the  stone  may  be  kept  immersed  in  the  alkaline 
fluid.      This  solvent  treatment  is  only  available  for  uric 
acid  stones,  alkaline  solutions  having  no  effect  on  phos- 
phatic  or  oxalate  of  Hme  calculi ;    whilst  with  those  which 


522  DISEASES    OF    THE    KIDNEy, 

are  soluble  in  acid  solutions,  it  is  found  practicably  im- 
possible to  administer  acid  in  sufficient  quantities  to  have 
the   shghtest   effect,   though  in  the   case   of  phosphatic 
calcuU  in  the  bladder,  washing  out  that  organ  frequently 
with  a  dilute  solution  of  HCl,  may  check  their  growth. 
In  renal  calculi,  for  the  reasons  already  stated,  the  alka- 
line solvent  treatment  has  little  effect  unless  the  calculus 
is  very  small  and  quite  recent,  in  fact,  still  in  almost  a 
nuclear  condition.     Then  the  continuous  administration 
of  liquor  potass©  or  citrate  of  potash  for  some  days  or 
weeks,    or   the  use   of  the   alkaline  waters  of  Yichy  or 
Contrexeville,  will  perhaps  bring  away  the  concretion  in  a 
partially  disintegrated  condition.      Should,  however,  the 
calculus  have  attained  a  fair  size,  the  administration  of 
alkaline  solvents   will  not  only  do  no  good  but  may  do 
positive  harm,  the  amount  of  alkali  taken,  especially  if  in 
the  form  of  bicarbonate,  having  a  tendency,  as  has  been 
shown  by  experiments  by  Parkes,  Beneke,  Bence  Jones, 
and  myself  {Lancet,  Nov.  9th,  1878),  to  render  the  urine 
more  highly  acid  after  the  immediate  effect  of  the  alkali 
has  passed  off;  whilst  withJarge  and  long-continued  doses 
of  alkah  unless  carefully  watched,  there  is  a  danger  of  in- 
ducing an  ammoniacal  state  of  the  urine,  which  greatly 
aggravates  the  existing  evils.      In  these  cases  I  fall  back 
upon  the  method  suggested  by  Dr.  Murray  of  Newcastle, 
some  few   years   back,   which   consists   of  administering 
large  quantities  of  soft  or  distilled  water.     This  method, 
which  is  suited  for  all  kinds  of  calcuH,  has  in  the  case  of 
renal  concretions  been   successful  in  my  hands,  especially 
when  alternated  with  alkahes,  in  the  case  of  uric  acid  cal- 
culi.     In  one  case  which  I  reported  to  the  Pathological 
Society  {Trans.,  vol.   xxxiii.,   p.  -206),   the   calculus   was 
passed  as  a  mere  shell  after  two  years  persistence  in  the 
use  of  soft  water,  with  occasional  doses  of  alkah.    In  other 


TBEATMENT  OF  EENAL  CALCULUS.  523 

■cases  ■with  smaller  calculi  the  treatment  has  been  less  pro- 
longed, and  they  have  come  away  much  eroded  on  the 
surface,  showing  that  a  diminution  of  then*  bulk  had  been 
effected.  In  carrying  out  this  treatment,  about  four  pints 
of  distilled  water  are  administered  daily,  the  patient  hav- 
ing no  other  supply,  the  tea  is  made  from  distilled  water 
supplied  in  gallon  jars  by  the  chemist,  and  for  drinking 
water,  the  distilled  aerated  water  supplied  by  the  "  Salu- 
taris  "  company  may  be  relied  on.  The  continued  use  of 
distilled  water  exercises  a  powerful  diuretic  action,  and 
the  specific  gravity  of  the  urine  becomes  very  low,  whilst 
the  inorganic  constituents,  especially  the  lime  salts,  are 
reduced  to  a  minimum.  The  solvent  action  of  distilled 
water  is  due  to  several  influences.  In  the  first  place  by 
■causing  a  low  specific  gravity  of  the  urine  it  induces  dis- 
.  integration  ;  since  Eainey  has  shown  experimentaUy  that 
bodies  placed  in  solutions  of  different  density  to  those  in 
which  they  were  formed  undergo  molecular  disintegration. 
Again,  chemical  analysis  has  shown  that  those  calculi  that 
undergo  spontaneous  disintegration  are  always  poor  in 
inorganic  constituents,  the  use  of  soft  water  diminishes 
the  supply  of  these  as  already  stated,  even  if  it  does  not 
actually  act  as  a  solvent  on  those  forming  the  outer  crust 
■of  the  calculus,  and  so  increases  the  tendency  to  disinte- 
grate. Lastly,  soft  water  probably  diminishes  the  catarrh 
of  the  urinary  passages,  and  by  diminishing  the  swelling 
•  of  the  mucous  membranes  allows  a  small  stone  to  pass, 
which  was  before  obstructed.  And  this  brings  us  to  the 
second  consideration  named  at  the  commencement  of  this 
paragraph,  viz.,  the  treatment  necessary  "  to  render  the 
urinary  passages  more  favourable  to  the  passage  of  the 
stone."  A  renal  concretion  cannot  exist  for  long  without 
setting  up  a  considerable  amount  of  pyelitis,  and  it  is  easy 
to  see  how  the  swelling  of  the  mucous  membranes  of  the 


624  DISEASES    OF    THE    KIDNEY. 

pelvis  of  the  kidney,  especially  the  folds  near  the  orifice  to 
the  ureter  will  obstruct  a  calculus  in  its  passage.  Although 
soft  water  relieves  this  condition,  still  we  have  a  more  sure 
and  rapid  agent  in  turpentine.  This  medicine  which  has 
gone  out  of  fashion  of  late  years,  had  formerly  a  great 
reputation  in  calculous  affections.  The  late  Dr.  Henery^ 
of  Manchester,  thought  the  subject  important  enough 
to  bring  before  the  Eoyal  Medical  and  Chirurgical  Society,, 
and  related  a  case  in  which  a  single  dose  brought  away  an 
enormous  accumulation  of  uric  acid  concretions.  Pepys, 
the  Diarist,  a  martyr  to  stone  and  gravel,  records  his 
favourable  experience  of  it.  For  my  part  I  have  found  it 
of  considerable  value.  After  a  few  doses,  even  if  the 
calculus  does  not  pass,  the  patient  becomes  easier,  and 
the  urine  less  purulent,  whilst  in  many,  the  adminis- 
tration is  followed  by  the  discharge  of  the  concretion. 
It  is  valuable,  too,  as  a  prophylactic  agent,  since  whilst  it 
renders  the  urinary  passages  more  free,  by  diminishing 
the  excessive  amount  of  mucus,  and  the  swelling  of  the 
mucus  surface,  it  removes  the  conditions  favourable  for 
the  retention  and  growth  of  any  subsequent  nucleus  that 
may  be  discharged  into  the  pelvis  of  the  kidney.  The  best 
mode  of  administration  is  in  the  form  of  capsules,  one  or 
two  every  night  or  morning. 

Encystment. — It  often  happens  that  after  death  we  find 
the  kidneys  the  seat  of  calculous  disease,  which  was 
unsuspected  during  life,  or  had  given  rise  to  little  or 
no  disturbance.  Thus,  in  the  case  of  a  lady  I  at- 
tended a  few  years  since,  and  who  died  at  the  age  of 
eighty-four,  her  left  kidney  had  attained  an  enormous 
size,  but  gave  her  little  pain  ;  this  calculous  mass  had 
been  growing  since  1840,  when  she  first  consulted  Dr.. 
Prout  for  irritability  of  the  bladder,  which  he  pronounced 
was  due  to  the  presence  of  this  stone  in  the  kidney.     In  a. 


TREATMENT  OF  RENAL  CALCULUS.  525 

post-mortem  made  on  a  sailor  in  the  Seamen's  Hospital, 
a  huge  branch-shaped  calculus  in  his  left  kidney  was 
found,  this  had  given  rise  to  no  symptoms  during  life,  as 
he  had  for  years  performed  his  duties  as  an  able  seaman, 
the  cause  of  his  death  being  rupture  of  the  hver  by  a  blow 
from  a  capstan  bar.  These  cases,  and  many  similar  ones, 
may  lead  us  to  hope  that  if  a  calculus  is  allowed  to  re- 
main quiescent  and  increase  in  size,  it  may  form  a  pouch 
for  itself  in  the  pelvis  of  the  kidney,  and  give  rise  to  little 
or  no  trouble  unless  disturbed  by  some  unwonted  exertion. 
If  therefore  it  happens  that  the  employment  of  the  solvent 
mode  of  treatment  gives  no  relief,  and  if  after  a  fair  trial 
there  is  no  amelioration  of  the  symptoms,  and  that  the 
stone  does  not  pass,  this  mode  of  treatment  ought  to  have 
a  fair  trial  before  operative  procedure  with  its  attendant 
risks  be  decided  on.  The  most  successful  case,  that  has 
come  under  my  notice,  is  that  reported  to  me  by  my  friend 
Mr.  Hicks  of  Eamsgate.  A  lady  who  suffered  from  re- 
peated attacks  of  cohc,  and  considerable  pyehtis,  dependent 
on  an  oxalate  of  hme  calculus  in  the  kidney,  and  who  was 
completely  worn  out  with  suffering,  was  induced  by  Mr. 
Hicks  to  remain  in  a  recumbent  position  for  six  months. 
At  the  end  ol  that  time  all  symptoms  of  pyelitis  subsided, 
and  the  patient  was  able  to  walk  about  and  be  driven 
without  any  feeling  of  discomfort  whatever.  In  the  case 
of  a  sailor,  admitted  at  the  Seamen's  Hospital,  with 
hsematuria  due  to  renal  calculus,  and  who  was  unable  to 
walk  across  the  ward  without  inducing  an  attack  of  colic, 
I  tried  this  treatment.  After  some  failures  caused  by  his 
restlessness,  I  managed  to  keep  him  in  bed  for  nearly  two 
months,  more  or  less  on  his  back.  At  the  end  of  that 
time  he  was  able  to  walk  about  the  grounds  of  the  Hospi- 
tal, and  was  free  from  pain,  and  ultimately  was  discharged 
with  a  view  of  joining  his  ship ;    from  that  time  I  have 


526  DISEASES    OF    THE    KIDNEY. 

heard  nothing  of  him,  so  I  cannot  say  if  the  rehef  was- 
permanent.  In  order  to  ensure  complete  success  by  this- 
mode  of  treatment,  the  rest  must  be  comj)lete,  and  the 
position  nearly  always  the  same,  viz.,  dorsal  but  rather 
inclining  to  the  affected  side.  The  discii^line  is  severe,  but 
if  rigidly  carried  out  is  likely  to  be  rewarded  in  suitable 
cases  with  success.  It  should  I  think  always  be  resorted 
to  in  cases  manifestly  unsuited  to  operative  relief.  Lastly,, 
if  we  fail  in  our  efforts  to  cause  the  stone  to  pass  into  the 
bladder,  or  to  render  it  quiescent  in  the  pelvis  of  the  kid- 
ney, then  if  the  patient  continues  to  suffer  from  repeated 
attacks  of  cohc,  with  considerable  pyelitis,  the  case  be- 
comes one  for  the  surgeon,  and  operative  procedure 
must  be  resorted  to  without  further  delay. 

Prophylactic  Treatment. — A  patient  having  got  rid  of  a 
stone,  it  must  be  our  endeavour  to  prevent  the  formation 
of  another.  For  this  purpose  the  patient  must  be  placed 
under  the  best  hygienic  conditions.  If  he  hves  on  a  cold 
damp  soil,  it  should  be  drained,  if  exposed  to  cold  easterly 
winds,  he  should  if  possible  winter  in  the  South,  and  on  a 
dry  sub- soil,  if  that  is  not  possible  he  should  clothe  him- 
self in  flannel,  especially  a  flannel  binder  round  his  loins, 
the  waistcoats  and  drawers  may  also  be  advantageously 
lined  with  chamois  leather.  He  should  continue  the  use 
of  soft  water.  If  the  tendency  be  toward  uric  acid  de- 
posits, the  condition  of  the  urine  must  be  attended  to, 
and  should  never  be  allowed  to  become  highly  acid  or 
concentrated.  Occasional  doses  of  biborate  of  soda  and 
citrate  of  potash  will  best  effect  this ;  whilst  on  the 
slightest  suspicion  of  lumbar  pain,  he  should  take  a  few 
doses  of  turpentine  with  a  view  of  clearing  the  urinary 
passages  of  mucus,  and  diminishing  any  catarrh. 

The  food  must  be  hght  and  easy  of  digestion,  and 
should  be   as  varied   as   possible.      Fish  should  be  the 


TKEATMENT    OF    RENAL    CAIiCULUS.  527. 

chief  article  of  animal  diet ;  white  meat  such  as  poultry 
and  lamb,  veal  and  pork  excepted,  should  be  preferred  to 
red  meats.     When  these  are  partaken  of,  it  is  as  well  to 
remember  that  the  neck  cutlets  of  mutton  and  the  fillet  of 
beef  are   more  juicy   and  tender  than  the  loin  chop  or 
rump  steak.     All  roast  meats  should  be  cooked  with  the 
gravy  retained  in  them.     Bread  should  be  eaten   stale, 
better  as  toast.     Potatoes,  except  in  the  form  of  "  chips," 
and  those  only  in  small  quantity,  are  to  be  avoided,  so 
also   all   flatulent  vegetables— cabbage,    spinach,    onions, 
turnips  and  peas  ;  in  their  place,  simple  salads  should  be 
freely  partaken  of.     Tomatoes  cooked  in  various  ways,  the 
soft  white  flower  of  the   spring  broccoli,  French  beans, 
stewed  celery,  sea-kale,  laver,  may  all  be  used.   Watercress 
should  be  served  at  every  meal.     Sweet  fruits  and  cooked 
fruits,   with   added  sugar,  must  be  forbidden.     But  the 
subacid  fruits  may  be  employed  in  moderation,  but  even 
these  may  occasion  heartburn  and  acidity,  and  give  rise  to 
cramp.     Pastry,  on  account  of  its  richness  and  the  sugar 
it  contains,  should  be  abstained  from,  but  plain  rice,  bread 
and  butter,  and  custard  puddings,  with  but  little  sugar, 
may  be  eaten  each  day  at  dinner  with  advantage.     Savoury 
omelettes,  caviare,  olives,  &c.,  need  not  be  forbidden  if 
partaken  of  in  moderation.     With  regard  to  the  use  of 
alcohol,  the  special  requirements  of  each  patient  must  be 
taken  into  consideration.     It  should  be  taken  in  as  dilute 
a  form  as  possible,  and  the  beverage  selected  must  also  be 
comparatively  free  from  sugar.     It  is  impossible  to  decide 
what  wine  will  suit  the  patient  best.     It  often  happens,  as 
Dr.  Prout  remarked  many  years  ago,  that  those  individuals 
who  have  long  been  accustomed  to  the  use  of  the  stronger 
wines,  as  port  and  sherry,  or  who  have  been  drinkers  of  ale, 
often  suffer  from  pains  in  the  back  and  gravel  when  they 
are  first  placed  upon  light  wines,  such  as  claret,  hock,  and 


■528  DISEASES    OF    THE    KIDNEY. 

champagnes,    and    this   is   especially  noticeable   in   cold 
weather.     It  is,  therefore,  as  well  to   make   no   sudden 
■change,  especially  with  elderly  people,  beyond  reducing  the 
quantity  and  substituting  a  dry  and  Hghter  port  or  sherry, 
if  the  taste  had  previously  been  towards  a  fuller  and  more 
bodied  wine.     When,   however,   the  light  wines  can  be 
taken  without  occasioning  gravel  or  pains  in  the  back,  the 
superior  growths  of  the  hght  clarets,  such  as   St.  Jullien 
and  St.  Estephe,  are  preferable  to  clarets  of  the  higher 
€lass,   such   as   La   Eose   or  Lafitte.      Zeltinger,  a   still 
Moselle,  is  also  a  wine  that  persons  suffering  from  uric 
acid  tendencies,  as  a  rule,  are  able  to  take  without  discom- 
fort.    All  wines  should  be  drank  dkectly  from  the  cask  or 
after  they  have  been  bottled  some  time.     Newly  bottled 
wines  are   most  pernicious.     Alcoholic  beverages  should 
only  be  indulged  in  once  during  the  day,  and  should  then 
be  taken  with  the  principal  meal.     As  the  digestive  powers 
are  usually  enfeebled  in  persons  who  have  suffered  long 
from  gout,  a  little  dilute  alcohol,  which,  as  Claude  Bernard 
has  shown  is,  next  to  the  saliva,  the  most  efficient  agent 
in  stimulating  the  gastric  secretion,  should  be  taken  at  the 
commencement  of  dinner.     The  best  form  is  a  tablespoon- 
ful  of  brandy  in  half  a  tumbler  of  water,  or  a  spoonful  of 
sherry  in  the  soup.     No   other  alcohol  should  be  taken 
during  dinner,  but  afterwards  a  couple  of  claret  glasses  of 
some  hght  wine  or  two  small  glasses  of  dry  port  or  dry 
sherry.     If  the  patient  is  very  weak  and  the  nights  are 
sleepless,  a  httle  brandy  or  whiskey  may  be  permitted  be- 
fore going  to   bed ;    this  is   best  taken  in  some  natural 
alkahne  effervescing  water. 

With  regard  to  the  treatment  of  oxaluria,  we  have  to 
consider  whether  the  deposit  manifestly  arises  from  the 
ingestion  of  articles  of  food  containing  crystals  of  oxalate 
of  hme,  in  which  case  it  wiU  be  sufficient  to  point  out 


TREATMENT  OF  RENAL  CALCULUS.  529 

what  these  are  and  to  discontinue  their  use.  If  the  de- 
posits, however,  arise  indirectly  from  the  food,  owing  to 
incomplete  oxidation  of  the  saccharine,  oleaginous,  and 
albuminous  principles,  it  will  be  necessary  carefully  to 
regulate  the  diet  with  regard  to  quantity  and  quality,  and 
to  promote  the  oxidising  processes  within  the  body  by 
means  of  iron,  change  of  air,  sea-bathing,  &c.  In  those 
cases  where  oxalate  of  hme  deposits  seem  to  arise  from 
increased  tissue  metabohsm,  as  evidenced  by  an  increase 
in  the  amount  of  the  urinary  constituents  more  especially 
the  urea  and  phosphoric  acid  excreted  daUy,  inquu'y  must 
be  made  into  the  nature  of  the  conditions  producing  such 
disturbance,  and  the  treatment  directed  accordingly.  In 
the  case  of  calculous  deposits  of  oxalate  of  lime  it  will  be 
profitable  to  remember  that  the  oxahc  acid  has  possibly 
its  origin  in  the  mucus  of  the  urinary  passages,  and  not 
necessarily  in  the  blood,  a  reflection  which  ought  to  du-ect 
our  attention  rather  to  the  treatment  of  any  local  morbid 
condition  that  may  exist  ia  them,  than  to  the  employment 
of  remedies  designed  to  act  on  the  system  generally. 
Lastly,  with  regard  to  these  cases  of  dyspepsia  associated 
with  more  or  less  persistent  deposits  of  oxalate  of  Hme, 
and  to  which  alone,  as  I  have  stated,  the  term  "  oxaluria  " 
seems  applicable  ;  oar  efiort  at  treatment  must  be  du-ected 
almost  entirely  to  the  relief  of  the  catarrhal  conditions  on 
which  the  dyspeptic  symptoms  depend.  This  is  best 
effected  by  the  systematic  employment  of  small  doses  of 
Carlsbad  salts  largely  diluted ;  a  teaspoonful  of  the  salt 
dissolved  in  ten  to  fifteen  ounces  of  hot  water,  as  hot  as 
the  patient  can  bear  it,  should  be  taken  every  other  morn- 
ing an  hour  before  breakfast.  This  diluted  warm  saline 
solution  seems  to  have  the  power  of  dissolving  and  remov- 
ing a  considerable  quantity  of  the  abnormal  mucus,  which 
in  undergoing  fermentative  changes  gives  rise  to  lactic  and 

MM 


530  DISEASES    OP    THE    KIDNEY. 

butyric  acids,  the  motions  which  result  from  its  use  con- 
taining not  only  fecal  matter,  but  much  offensive  glutinous- 
looking  sUme.  Thirty-grain  doses  of  bismuth  should  be 
administered  once  or  twice  a  day  before  meals,  and  Dr. 
Front's  mixture  of  nitro-muriatic  acid  and  nux  vomica 
may  be  prescribed  with  advantage,  especially  in  long- 
standing cases  when  there  is  much  mental  depression, 
about  two  or  three  hours  after  food.  The  patient  should 
remove  to  a  dry  soil,  but  if  that  is  not  possible,  the 
greatest  attention  should  be  paid  to  the  subsoil  drainage  of 
his  house.  The  use  of  a  cold-water  compress  over  the  ab- 
domen at  night  will  be  found  advantageous,  not  only  in 
reUeving  the  abdominal  catarrh,  but  in  protecting  the 
patient  against  a  return  of  the  malady.  The  diet  should 
be  nutritious  and  digestible,  with  a  Uberal  allowance  of 
meat,  fish,  poultry,  and  game.  The  bread  should  be  eaten 
stale,  or  better  still,  toasted.  Sugar  and  all  farinaceous 
food  should  be  avoided  as  much  as  possible  without  actu- 
ally restricting  them,  and  flatulent  vegetable  food  alto- 
together  discarded.  Tea  may  be  used  in  moderation,  but 
coffee  and  alcohol  are  positively  injurious. 

With  regard  to  the  treatment  of  persistent  deposition  of 
earthy  phosphates  the  main  indications  are  rest  and  an 
endeavour  to  promote  nutrition  generally.  To  attain  this 
end  opium  or  codeia  should  be  given  in  full  doses,  when 
the  patient  first  comes  under  observation.  As  soon,  how- 
ever, as  the  nervous  system  is  quieted,  and  the  rheumatic 
andf  neuralgic  pains  are  less  severe,  it  should  be  discon- 
tinued, lest  it  interfere  with  digestion.  General  tonics, 
such  as  iron,  phosphorus,  quinine,  nux  vomica,  hydro- 
chloric acid,  and  cod-liver  oil  should  be  persevered  with. 
When  there  is  a  history  of  syphilis,  iodide  of  potassium 
should  be  combined  with  these  remedies.  Warm  baths, 
followed  by  tepid  douches,  give  great  reHef  to  the  neuralgic 


TEEATMENT  OF  EENAL  CALCULUS.  531 

pains,  and  also  soothe  the  nervous  system.  The  soluble 
phosphates  may  be  administered ;  but  their  utility  in  these 
cases  is  questionable.  There  appears  to  be  no  lack  of 
these  constituents  in  the  system  ;  the  difficulty  seems 
rather  to  lie  in  the  want  of  power  of  the  tissues  to  retain 
them.  The  food  should  be  light  and  nutritious,  and  milk 
one  of  the  chief  constituents.  Alcohol  should  be  avoided  ; 
it  invariably,  even  in  small  quantities,  increases  the 
diuresis.  The  same  may  be  said  of  coffee.  Change  to  dry, 
bracing  air  should  be  obtained  if  possible.  The  clothing 
should  be  warm,  and  the  patient  carefully  guarded  against 
cold,  since  in  these  cases  a  reduction  of  bodily  temperature 
is  always  noted. 

When  the  urine  is  alkaline  from  the  presence  of  car- 
bonate of  ammonia,  we  may  endeavour  to  prevent  the 
formation  of  ammonio-magnesium  phosphate  concretions  by 
the  administration  internally  of  boracic  acid,  or  benzoic 
acid ;  after  a  fair  trial  of  both,  I  think  the  former  the 
most  satisfactory,  the  prescription  given  at  p.  290  is  per- 
haps the  best  way  of  administering  it.  It  may  be  taken 
for  long  periods  of  time  together,  without  in  any  way 
affecting  the  general  health.  Turpentine  too  is  very  use- 
ful in  this  condition,  since  it  diminishes  the  catarrh  of  the 
urinary  passages  which  is  always  more  or  less  present. 
The  bladder,  if  affected,  should  be  washed  out  systemati- 
cally, either  with  a  dilute  solution  of  hydrochloric  acid  and 
quinine,  or  of  boracic  acid  (p.  291).  Although  in  spite  of 
all  our  efforts  we  may  find  it  impossible  to  restore  the  urine 
to  its  normal  reaction,  yet  by  persistently  using  the  above 
means  we  can  generally  prevent  the-  formation  of  a  triple 
phosphate  concretion,  and  also  relieve  the  patient  from  the 
many  discomforts  attendant  on  an  ammoniacal  state  of 
urine. 


MM  2 


532  DISEASES    OF    THE    KIDNEY. 


CHAPTEE  XI. 
Functional    Albushnuria,   Peptonuria,   Hemoglobinuria. 

Functional  Albuminuria. 

173.  Classification. — Writing  as  far  back  as  1842, 
Simon  remarked  that  "  albuminous  urine  is  so  frequently 
observed  in  numerous  deranged  states  of  tlie  organism, 
independent  of  Brigbt's  disease,  that  the  idea  tbat  granular 
degeneration  of  '  the  kidneys  necessarily  exists,  wben 
albuminuria  occurs,  must  be  abandoned."  Again,  in  1852, 
Mialbe  asserted  that  digested  albumin  (peptone)  occa- 
sionally appears  in  the  urine  independently  of  any  ap- 
parent renal  lesion.  Whilst  Gigon,  in  1858,  went  so  far 
as  to  state  that  albumin  existed  in  normal  urine.  So  little 
impression,  however,  did  these  observations  make,  at  all 
events  in  England,  that  though  Parkes,  Eoberts,  and 
other  writers  on  urinary  pathology,  alluded  to  the  fact  that 
albuminuria  might  occur  independently  of  Bright's  disease, 
and  in  connection  with  general  disorder  of  the  system, 
still  the  fact  never,  till  quite  recently,  seemed  to  impress 
itself  on  the  attention  of  the  profession  generally.  Since, 
however,  the  practice  of  systematically  examining,  for 
albumin  and  sugar,  the  urines  of  all  patients  that  come 
under  our  observation,  and  of  those  who  are  referred  to  us 
for  "Hfe  assurance,"  has  become  general,  the  subject  has 
received  considerable  attention,  and  very  valuable  addi- 
tions have  been  made  to  our  knowledge  with  respect  to  it. 

And  first  with  regard  to  the  so-called  physiological 
albuminuria.     As  already  stated,  as  far  back  as   1858, 


PUNCTIONAI.   ALBUMINUBIA.  533 

Gigon  asserted  that  albumin  existed  in  normal  urine. 
Becquerel,  however,  who  carefully  went  into  the  question 
at  the  time,  conclusively  showed  that  the  precipitate 
obtained  by  Gigon  was  not  albumin,  but  a  mixture  of 
mucin  and  other  organic  substances.  With  the  intro- 
duction of  more  delicate  reagents  for  the  detection  of 
albumin,  Gigon's  idea  has  revived,  and  many  hold  that 
a  minute  trace  of  albumin  is  present  normally  in  all 
urines,  or  at  all  events  in  the  urine  passed  after  food  or 
after  exercise,  and  that  an  exaggeration  of  the  physiologi- 
cal condition,  such  as  an  indigestible  meal,  or  strong 
exercise,  may  lead  to  a  very  perceptible  increase  in  the 
amount  passed  into  the  urine.  Thus  Leube,  who  ex- 
amined the  urine  of  soldiers  after  a  long  march,  found 
albumin  in  sixteen  per  cent,  of  the  urines  examined; 
whilst  Capitan  who  examined  the  urine  of  ninety- seven 
children  at  the  Hopital  des  Enfants  Assistes,  found  albu- 
min in  thirty-eight  instances,  in  quantities  varying  from 
•007  to  "02  grm.  in  the  litre.  Chateaubourg  also  found 
albumin  in  seventy- six  urines  out  of  ninety- four,  passed 
by  soldiers  five  hours  after  a  meal.  On  the  other  hand 
Oertels  who  experimented  on  a  considerable  number  of 
individuals,  some  of  whom  were  invalids,  and  some  women 
and  children,  by  making  them  ascend  heights  of  various 
degrees  of  steepness,  only  found  albumin  in  three  per 
cent,  of  the  cases  submitted  to  the  experiment.  This  lat- 
ter observation  closely  accords  with  my  experience,  for  out 
of  more  than  sixty  examinations  made  for  "hfe  assurance  " 
in  persons  otherwise  apparently  healthy,  I  have  met  with 
temporary  albuminuria  but  twice.  The  discrepancy  existing 
between  the  results  obtained  by  Leube  (sixteen  per  cent.), 
Capitan  (thirty-nine  per  cent.),  Chateaubourg  (eighty- 
one  per  cent.),  and  those  of  Oertels  (three  per  cent.)  re- 
quires explanation,  which  I  believe  is  to  be  found  in  the 


534  DISEASES    OF    THE    KIDNEY. 

circumstance  tliat  the  first  named  observers  did  not  em- 
ploy tests  that  sufficiently  distinguished  between  serum, 
albumin,  and  other  proteid  bodies,  such  as  mucin,  pep- 
tones, etc.,  that  might  happen  to  be  present,  and  also  by 
not  always  having  rigidly  excluded  the  possibility  of  extra- 
renal albuminuria. 

Thus  Capitan  and  Chateaubourg  relied  on  potassio- 
mercuric  iodide,  which  as  we  know  has  a  wide  range  of 
action,  precipitating  as  it  does  mucin,  peptones,  hemi- 
albumose  urates,  and  alkaloids,  and  mistakes  are  liable  to 
arise  unless  heat  is  employed  as  well,  to  confirm  the  pre- 
sence of  serum  albumin ;  and  we  are  informed  that  in  the 
case  of  ninety-four  soldiers,  whilst  potassio-mercuric  iodide 
gave  a  precipitate  with  seventy-six  urines,  heat  only  once 
proved  the  presence  of  albumin.  Again,  with  regard  to 
Leube's  observations,  though  the  nature  of  the  test  em- 
ployed is  not  stated,  still  it  is  not  unreasonable  to  suppose 
that  among  soldiers,  a  considerable  proportion  had  suf- 
fered from  urethral  trouble  at  no  very  distant  date,  and 
though  sufficiently  recovered  as  to  permit  them  to  per- 
form their  ordinary  regimental  duties,  a  long  march  might 
still  excite  a  muco-purulent  discharge.  Again,  the  effect 
of  the  pressure  on  the  chest,  from  the  weight  of  the  knap- 
sack and  other  accoutrements,  would  probably  in  some 
cases  occasion  a  degree  of  venous  obstruction  sufficient  to 
account  for  the  albuminuria.  I  have  repeatedly  examined 
urines  passed  by  apparently  healthy  persons,  supposed 
to  contain  albumin,  but  with  the  exception  of  the  two 
instances  above  mentioned,  I  have  failed  to  satisfy  myself 
of  its  being  physiological  albumin.  Either  it  has  proved 
to  be  some  other  proteid  body,  such  as  mucin,  peptone, 
hemi-albumose,  etc.,  or  else  on  microscopic  examination 
of  the  urine  I  have  found  the  mucous  membrane  of  the 
genito-urinary  tract  inflamed  as  from  an  old  gleet,  slight 


FUNCTIONAL    ALBUMINURIA.  535 

cystitis  from  cold,  or  pyelitis  from  gravel.  But  though  I 
do  not  believe  in  the  existence  of  a  physiological  albu- 
minuria, I  am  ready  to  admit  that  in  some  persons,  ap- 
parently strong  and  well,  albumin,  just  as  sugar  does 
in  others,  passes  into  the  urine  on  very  trifling  exaggera- 
tions of  ordinary  physiological  conditions. 

But  if  we  examine  the  urine  of  those  acknowledged  to 
be  suffering  from  definite  disease,  we  find  a  much  more 
frequent  occurrence  of  albuminuria.  This  varies  with 
the  class  of  cases  that  come  under  observation ;  thus, 
among  out-patients  with  a  great  proportion  of  slight 
maladies,  albuminuria  will  be  noticed  in  about  twenty- 
seven  per  cent,  of  the  urines  examined,  whilst  with  in- 
patients, among  whom  are  to  be  found  cases  of  heart 
disease  in  the  last  stage,  pneumonia,  pleurisies,  and 
other  acute  febrile  affections,  the  percentage  is  far  higher 
and  may  be  placed  at  forty-seven ;  thus  giving,  if  both 
classes  of  cases  be  taken  together,  an  average  percen- 
tage of  thirty- six.  The  statistics  of  different  observers, 
however,  vary  as  regards  this  point ;  thus  Parkes  puts  the 
percentage  for  men  in  hospital  cases  at  37'05,  Dickinson 
at  39,  both  of  which  agree  closely  with  mine  ;  whilst 
Saundby  states  that  out  of  145  out-patients  he  found  the 
urine  albuminous  in  104.  Further,  if  we  analyse  these 
thirty-six  cases  we  shall  find  about  twenty-one  per  cent., 
according  to  my  figures,  are  due  to  organic  changes  in 
the  structure  of  the  kidney,  such  as  diffuse  inflammation, 
cyanotic  induration,  waxy  degeneration,  etc.,  and  about 
eleven  per  cent,  due  to  disease  of  the  lower  urinary  pas- 
sages or  to  pyrexia,  etc.,  whilst  the  remaining  four  per  cent. 
may  be  fairly  termed  functional  albuminuria,  due  either  to 
derangements  of  digestion,  disturbances  of  innervation,  or 
an  altered  condition  of  the  blood. 

1.  Derangements  of  digestion. — In  the  majority  of  cases 


536  DISEASES    OF    THE    KIDNEY. 

the  albuminuria  occurs  only  after  the  ingestion  of  food, 
and  appears  to  be  caused  by  the  presence  of  some  more 
diffusible  form  of  albumin  than  serum  albumin,  such  as 
ov- albumin  in  the  case  of  the  albuminuria  after  eating 
largely  of  eggs,  or  casein,  as  in  the  instances  recorded  by 
Christison,  after  eating  cheese.  But,  in  many  cases,  the 
presence  of  albumin  in  the  urine  after  food  seems  to  de- 
pend on  the  non- assimilation"  of  proteid  substances  in  the 
stomach  and  intestinal  canal,  just  as  sugar  appears  in  the 
urine  owing  to  the  non- assimilation  of  starchy  and  sac- 
charine matters  in  the  liver.  That  this  may  be  a  probable 
cause  of  digestive  albuminuria  has  been  shown  experi- 
mentally by  Parkes,  Bernard,  Stokvis,  and  Gubler.  In 
other  cases,  the  albuminuria  is  ushered  in  with  a  feeling 
of  nausea,  and  is  attended  with  marked  disturbance  of  the 
hepatic  function,  shown  by  the  decided  icteric  tint  of  the 
skin,  and  vague  dyspeptic  attacks ;  in  these  cases  the  urea 
ehminated  is  usually  increased  in  quantity.  This  latter 
form  of  albuminuria,  which  has  been  designated  "  hepatic 
albuminuria,"  resembles  somewhat  in  its  character  that  of 
paroxysmal  haemoglobinuria,  only  the  colouring  matter  of 
the  blood  is  absent  from  the  urine.  Many  of  these  cases 
of  albuminuria,  apparently  dependent  on  functional  de- 
rangements of  the  liver,  are  glycosuric  as  well.  Finally, 
what  may  be  termed  "digestive  albuminuria,"  is  occasion- 
ally observed,  when  a  small  quantity  of  serum  albumin 
diffuses  through  with  peptones  (p.  110). 

2.  Disturbed  innervation. — Experiments  on  animals  have 
shown  that  albuminuria,  accompanied  by  a  profuse  flow 
of  urine,  follows  section  of  the  renal  nerves  ;  whilst  punc- 
ture of  the  floor  of  the  fourth  ventricle,  a  little  higher  up 
than  is  required  to  cause  glycosuria,  and  irritation  of 
the  sympathetic  in  the  neck,  are  also  attended  by  the  pre- 
sence of  albumin  in  the  urine.     Albuminuria  has  also  been 


FUNCTIONAL    ALBUMINUBIA.  537 

produced,  though  in  a  lesser  degree,  by  u-ritation  of  the 
sciatic  nerve,  or  of  the  plexus  of  nerves  over  the  intestines. 
•Capitan  has  also,  shown,  that  irritation  of  special  nerve 
■centres — the  auditory  by  detonations,  the  retina  by  strong 
light,  sometimes  causes  transient  albuminuria.  Neurotic 
albuminuria  may  be  observed  clinically  in  some  persons 
after  a  cold  bath  or  exposure  to  cold.  It  has  been  sug- 
gested that  the  albuminuria  thus  produced  is  only  a  minor 
manifestation  of  paroxysmal  hEemoglobinuria,  only  in  this 
case  the  colouring  matter  of  the  corpuscles  is  not  dis- 
solved out.  It  may  also  be  produced  by  purely  mental 
causes,  such  as  the  prolonged  study,  with  anxiety,  atten- 
dant upon  competitive  examinations.  These  cases  of 
albuminuria  are  more  frequently  observed,  I  am  con- 
vinced, among  students  residing  in  London,  or  large 
towns,  than  among  the  members  of  the  two  Universities, 
where  the  conditions  of  life  are  more  healthy,  and  where 
better  opportunities  exist  for  getting  fresh  air  and  exer- 
<3ise.  One  reason,  perhaps,  that  the  condition  seems 
more  prevalent  among  students  of  the  medical  profession 
than  among  others,  is,  that  they  are  accustomed  when  out 
of  health  to  test  their  own  urine,  and  so  discover  a  symp- 
tom that  might  otherwise  have  passed  unnoticed.  In  one 
-case  I  have  seen  albuminuria  apparently  induced  by  sheer 
;anxiety.  A  healthy  young  man  presented  himself  for 
*' life  assurance  "  and  would  have  passed  as  a  first-class 
Hfe,  but  his  urine  was  found  loaded  with  albumin.  His 
medical  attendant  who  learnt  the  cause  of  his  rejection, 
was  unable  to  find  in  any  subsequent  sample  passed  the 
smallest  trace  of  albumin,  and  he  therefore  assumed  I 
was  mistaken  ;  it  was  therefore  arranged  he  should 
■undergo  another  examination,  but  the  very  morning  he 
was  to  come  to  town  for  that  purpose  the  urine  was  again 
found  to  be  albuminous.      Neurotic  albuminuria,  as  has 


538  DISEASES    OF    THE    KIDNEY. 

been  pointed  out  by  Dr.  Dukes  (Brit.  Med.  Jour.,  vol.  ii.,, 
1878),  is  not  uncommon  among  adolescents,  in  many 
cases  it  may  be  referred  to  over- work  and  ill-health,  but 
in  some  it  is  undoubtedly  connected  with  the  practice  of 
masturbation.  Dr.  Matthews  Duncan  [Med.  Chir.  Trans., 
1885)  has  also  pointed  out  the  intimate  connection  that 
exists  between  the  internal  genital  organs  and  the  kid- 
neys, and  the  frequency  with  which  parametritis  is  accom- 
panied with  albuminuria.  Transient  albuminuria  has 
also  been  met  with  after  injuries  to  the  head,  during 
epileptic  convulsions,  in  tetanus,  and  in  exophthalmic 
goitre. 

3.  Altered  conditions  of  the  blood. — It  is  often  difficult  to 
determine  whether  the  albuminuria  is  caused  by  changes 
in  the  blood  itself,  or  is  induced  by  the  irritation  in  the 
kidneys,  set  up  by  the  elimination  of  poisonous  substances 
through  them.  Thus  for  instance,  in  the  case  of  the  ab- 
sorption of  purulent  collections  from  the  body,  the  blood 
poisoning  from  malaria,  jaundice,  scurvy,  purpura,  syphiHs,. 
etc.,  or  the  poisoning  by  phosphorus,  mercury,  lead,  etc., 
a  certain  degree  of  nephritis  undoubtedly  exists.  On  the 
other  hand  it  is  probable  that  variations  in  the  specific 
gravity  of  the  blood  may  induce  transient  albuminuria. 
Thus  for  instance,  I  have  found  occasional  traces  of  albu- 
min not  at  all  infrequent  in  the  urines  of  corpulent  elderly 
Xjersons,  who  habitually  secrete  a  rather  dense  urine,  con- 
taining an  excess  of  urea.  These  cases  are  often  spoken  of 
as  *' gouty  albuminuria,"  and  it  may  be  so,  although  in 
many  cases  I  have  had  no  reason  to  suppose  the  patient  to 
be  gouty  ;  I  have,  however,  satisfied  myself  that  in  some 
of  those  cases  that  have  come  under  my  observation,  the 
albuminuria  was  not  caused  by  any  organic  changes  in 
the  kidneys,  nor  that  the  albumin  was  derived  from  pus 
caused  by  irritation  of  the  excretory  tract,  from  deposited. 


FUNCTIONAL   ALBUMINURIA.  539' 

uric  acid,  urates  or  oxalates.  I  am  therefore  inclined  to 
think  that  in  these  instances,  the  albuminuria  was  caused 
by  a  functional  exhaustion  of  the  renal  epithelium  brought 
about  by  a  long- continued  over- elimination  of  urinary 
solids. 

Again  in  the  puerperal  state  there  is  often  an  albumin- 
uria, which  must  be  distinguished  from  the  albuminuria 
of  puerperal  nephritis  (p.  246)  as  being  unattended  with 
dropsy  or  eclampsia.  This  form  of  albuminuria  is  often 
accompanied  with  slight  jaundice,  and  is  usually  some- 
what intermittent,  indeed  occasionally  paroxysmal  in  its 
character,  being  abundant  at  one  time,  whilst  hardly  a 
trace  can  be  found  at  another.  Thus  in  one  case  the 
morning,  noon  and  afternoon  samples  contained  but  the- 
merest  trace,  whilst  the  evening  urine  was  always  loaded, 
even  when  the  patient  was  kept  in  bed.  This  form  of  al- 
buminuria depends,  I  think,  on  some  altered  condition  of 
the  blood  in  the  puerperal  state.  Albuminuria  will  occa- 
sionally be  observed  in  some  females  about  the  menstrual 
period,  often  associated  with  a  slight  transient  jaundice 
(icterus  menstrualis) . 

With  regard  to  the  causation  of  functional  albuminuria^ 
under  any  of  the  above  named  conditions,  we  must,  in  ac- 
cordance with  the  conclusions  arrived  at  (p.  167),  where 
we  considered  the  causation  of  albuminuria  generally, 
infer  that  the  primary  cause  lies  in  a  deranged  function 
of  the  glomerular  or  tubular  epithelium,  though  no  doubt 
the  secondary  causes  are  numerous.  Thus  in  the  albu- 
minuria referred  to  derangements  of  digestion,  a  more 
diffusible  albumin  may  be  brought  to  the  epithelium,  or  as 
Dr.  Lauder  Brunton  {Lettsomian  Lectures,  1885)  has  sug- 
gested the  albumin  may  be  presented  in  a  state  of  finer 
molecular  sub-division.  In  neurotic  albuminuria  the: 
functions  of  the  renal  epithelium  are  disturbed,  by  varia- 


540  DISEASES    OF    THE    KIDNEY. 

tions  of  pressure  in  the  circulation,  brought  about  by  the 
"vaso-motor  nerves.  In  certain  cases  this  may  be  so  great 
as  to  lead  to  considerable  hypersemia.  In  some  cases  the 
functions  of  the  epithelium  may  be  arrested  by  the  direct 
action  of  some  toxic  agent  on  them,  as  in  Dr.  Eobertson's 
experiment  (p.  161)  with  atropine,  whilst  in  others  the 
epithelium,  as  already  stated,  may  become  exhausted  by 
habitual  over  stimulation. 

As  a  rule  there  is  little  difficulty  in  determining  be- 
tween functional  and  organic  albuminuria.  In  the  former 
"though  the  albumin  may  be  abundant  it  is  rarely  per- 
sistent, and  many  samples  may  be  passed  throughout 
the  day  perfectly  free  from  albumin.  Again,  even  if 
the  albumin  should  persist,  functional  can  be  distin- 
guished from  organic  albuminuria,  by  the  fact  that  the 
•other  evidences  of  organic  disease  are  absent,  thus  there  is 
no  dropsy ;  no  epithelial  casts  for  when  these  occur  in 
transient  albuminuria,  we  must  suspect  that  a  slight 
degree  of  nephritis  also  exists ;  no  great  diminution  in  the 
■excretion  of  urea  as  in  tubal  nephritis ;  no  ursemic  convul- 
sions or  cardio-vascular  changes  as  in  chronic  interstitial 
nephritis  ;  whilst  febrile  reaction  serves  to  distinguish  the 
transient  albuminuria  which  often  accompanies  pyrexia! 
conditions  from  functional  albuminuria.  The  presence  of 
pus  in  the  urine  will  enable  us  to  distinguish  between  dis- 
ease of  the  urinary  passages,  and  albuminuria  the  result 
of  functional  disturbance. 

174.  Treatment. — In  the  majority  of  cases,  rest, 
-change  of  air,  and  the  administration  of  tonic  medicines 
are  sufficient  to  cause  a  disappearance  of  the  albumin  in 
the  urine.  In  the  albuminuria'  dependent  upon  digestive 
derangements,  special  attention  must  be  paid  to  these  or- 
gans. In  most  of  the  cases  some  evident  derangement  of 
the  liver  is  manifest  as  marked  by  saUowness,  and  an  in- 


FUNCTIONAL    ALBUMINURIA.  541 

crease  in  the  amount  of  urea  excreted,  and  deposits  of 
oxalate  of  lime.  The  albuminuria  is  always  aggravated 
when  the  bowels  are  constipated,  or  by  meals  consisting 
chiefly  of  animal  food,  ^  The  diet  therefore  should  be  light, 
though  nutritious,  and  farinaceous  articles  with  abundance 
of  fruit  and  vegetables  should  replace  meat.  I  have  found 
the  continued  administration  of  nitro-muriatic  acid  with 
nux  vomica  very  serviceable  in  these  cases,  together  with 
the  frequent  use  of  purgative  mineral  waters.  The  patients,. 
too,  are  much  benefited  by  the  daily  use  of  tepid  saline 
douches  (85°  F.).  Two  cases  I  had  under  my  care  last 
year,  lost  all  traces  of  albuminuria  after  employing  the 
above  treatment  for  a  short  while.  One,  a  gentleman 
from  America,  a.ged  sixty-five,  sent  me  by  my  col- 
league Mr.  Couper,  had  noticed  albumin  in  his  urine 
for  some  months  previously,  and  feared  he  was  suffering 
from  chronic  renal  disease.  All  the  specimens  I  examined 
contained  albumin,  but  those  passed  after  meals  had  it  in 
abundance.  The  specific  gravity  averaged  1025,  and  there 
was  an  abundant  deposit  of  oxalates.  This  patient  took 
nitro-muriatic  acid  and  nux  vomica,  and  went  to  Hom- 
bourg  where  he  drank  the  waters,  which  acted  freely,  and 
adopted  a  strict  regimen.  In  about  five  weeks  all  trace  of 
albumin  had  disappeared,  and  had  not  returned  when  I  saw 
him  some  time  afterwards.  The  other  case  was  that  of 
a  medical  man  in  the  West  of  England,  he  had  found  al- 
bumin in  his  urine,  which  was  always  most  abundant  after 
suffering  from  dyspeptic  attacks,  he  was  sallow,  and  the 
urine  had  a  high  specific  gravity,  1028,  contained  an  excess 
of  urea,  and  deposited  oxalates  in  great  quantities.  He  was 
also  placed  on  nitro-muriatic  acid  and  nux  vomica,  and 
was  ordered  to  take  every  other  morning  an  efficient  dose  of 
some  mineral  purgative  water.  Some  months  after  he 
wrote  to  say  he  had  experienced  the  greatest  benefit  from 


542  DISEASES    OF    THE    KIDNEY. 

ihe  free  purgation,  and  that  so  long  as  he  attended  to  the 
condition  of  his  bowels,  his  urine  never  contained  traces  of 
albumin. 

Peptonubia. 

175.  The  cHnical  significance  of  the  occurrence  of  pep- 
tones in  the  urine,  together  with  the  tests  by  which  their 
presence  is  detected,  has  already  been  discussed  (see  pp. 
108-111). 


Paroxysmal  Hzemoglobinueia. 

176.  Symptoms. — The  prominent  symptom  is  the 
paroxysmal  discharge  of  bloody  urine.  The  intermediate 
samples  being  usually  normal,  or  at  all  events  free  from 
blood.  The  next  point  of  importance  is  the  fact  that  on 
microscopic  examination,  no  red  corpuscles,  or  only  a  few, 
are  to  be  detected  in  the  bloody  urine,  a  circumstance 
•which  distinguishes  this  disorder  from  hasmaturia.  The 
paroxysm  is  usually  ushered  in  with  a  distinct  chill,  or  even 
rigor,  the  hands,  face,  or  any  part  of  the  body  that  may  be 
exposed,  often  become  Hvid  and  in  some  cases  urticaria 
appears  on  exposed  parts  of  the  skin.  Other  symptoms 
are  occasionally  present  such  as  headache,  drowsiness,  and 
great  thirst.  Colicky  pains  in  the  abdomen,  sometimes 
accompanied  with  nausea  and  vomiting,  are  by  no  means 
infrequent,  whilst  the  kidneys  are  somewhat  tender  when 
pressure  is  made  over  them.  The  patient  has  usually  an 
icteric  tint  at  the  time  of  the  attack,  which,  however, 
generally  becomes  more  marked  as  the  paroxysm  passes 
off.  The  temperature  is  often  elevated  at  the  commence- 
ment of  the  paroxysm,  and  may  be  followed  by  sweating. 
A  rise  of  temperature  is  not,  however,  an  invariable  ac- 


H^MOGLOBINUEIA.  543 

companiment.  The  urine  passed  during  the  paroxysm 
in  well  marked  cases  is  of  port  wine  colour,  though  in 
sHght  ones  it  may  have  only  a  reddish  tinge.  When  ex- 
amined by  the  spectroscope  the  characteristic  bands  of 
oxyhemoglobin  can  be  detected,  and  in  addition  a  third 
absorption  band,  that  of  methaBmoglobin  can  often  be 
detected.  On  standing,  the  urine  deposits  an  abundant 
■dirty  brown  sediment.  This  deposit  consists  chiefly  of 
urinary  epithehum,  the  nuclei  of  which  are  often  stained 
with  blood  pigment,  amorphous  urates,  pigment  matter. 
In  some  cases,  brownish  looking  casts  may  be  observed, 
which  are  probably  hyaline  casts  containing  hsemoglobin 
or  hsematin  crystals,  bilirubin  crystals,  and  the  pigmented 
ddbris  of  disintegrated  blood  corpuscles  may  be  observed ; 
rarely  granular  casts  may  be  present.  Crystals  of  uric 
acid  and  of  oxalate  of  lime  may  be  observed  in  some  urines, 
but  their  presence  is  by  no  means  universal.  Hematin 
crystals  have  been  observed  in  some  few  instances,  prob- 
ably they  are  formed  in  the  urine,  subsequent  to  emission, 
owing  to  decomposition  changes  in  that  fluid.  The  blood 
corpuscles  are  entirely  absent  in  the  majority  of  cases, 
though  occasionally  a  few  may  be  observed,  but  never  in 
quantity  sufficient  to  account  for  the  coloration.  They 
may  be  observed  in  one  attack  and  absent  in  the  next. 
Afanassieu  [ArcMvf.  Klin.  Med.,  Bd.  vi.,  1883)  has  pointed 
out  an  important  fact  that  whilst  the  colouring  matter 
generally  appears  in  the  form  of  granules,  found  with  the 
casts  and  sediment,  sometimes  no  granules  are  deposited, 
but  the  colouring  matter  remains  entirely  in  solution. 
The  paroxysmal  urine  is  always  albuminous,  and  contains 
serum  albumin  as  well  as  paraglobuHn.  It  has  been 
stated  that  the  coagulated  albumin  instead  of  sinking  to 
the  bottom  of  the  test  tube  floats  on  the  surface  of  the 
urine.     This  peculiarity  has  been  absent  in  all  the  cases 


544  DISEASES    OF    THE    KIDNEY. 

that  have  come  under  my  observation,  and  others  have' 
failed  to  observe  it  as  a  constant  phenomenon.  In  the 
majority  of  cases  the  urea  is  increased,  and  consequently 
the  specific  gravity  remains  high,  although  the  amount  of 
urine  passed  is  generally  above  the  average.  The  reaction 
of  the  urine  is  generally  acid,  rarely  alkaline,  when  freshly 
passed.  Such  are  the  characters  of  the  urine  passed 
immediately  after  the  chill,  the  succeeding  samples  being 
either  quite  natural,  or  only  containing  small  quantities  of 
blood  which  become  less  and  less  each  time  the  urine  is 
passed.  In  cases,  however,  in  which  the  paroxysms  are 
frequent,  the  urine  has  not  time  to  clear  itseK  between 
whiles,  so  that  the  passage  of  bloody  urine  seems  to  be  con- 
tinuous. A  little  discrimination,  however,  will  show  us 
that  one  sample  is  darker  than  others.  The  albumin 
generally  entirely  disappears  between  the  paroxysms, 
especially  if  they  are  not  frequent,  though  I  have  seen  a 
case  in  which  a  trace  of  albumin  was  found  in  the  urine 
some  months  after  the  paroxysms  had  ceased ;  it,  however, 
finally  disappeared.  I  have  found  the  interparoxysmal 
urine  to  have  somewhat  a  lower  specific  gravity  than 
that  passed  by  the  same  patient  during  the  attack,  whilst 
the  urea  is  never  in  excess  but  may  be  less  than  normal. 
Often,  too,  the  urine  remains  somewhat  dark,  not  from 
blood,  but  from  a  tendency  to  deposit  orange-brown 
amorphous  urates.  In  one  instance  (Lancet,  Nov.  17, 1883) 
I  have  observed  the  interparoxysmal  urine  to  be  distinctly 
chylous,  I  believe  this  to  be  the  only  case  in  which  this 
has  been  noticed.  In  the  majority  of  instances  the 
general  health  is  Httle  affected,  beyond  the  initial  disturb- 
ance ushering  in  the  paroxysms,  the  patient  may  feel  quite 
well.  In  some  cases,  however,  the  patient  feels  weak  and 
languid  and  becomes  decidedly  anaemic.  This  was  the 
case    with    a  patient    I    saw    last  November  with  Dr. 


HiEJIOGLOBINUKIA.  545 

Humphry  of  Chislehurst,  wlao  for  more  than  a  fortnight 
had  a  daily  febrile  exacerbation  lasting  some  hours,  rang- 
ing from  100°  to  102-5°F,  followed  by  sweating.  In  this 
instance  the  urine  was  never  quite  free  from  blood  colour- 
ing matter,  and  it  was  necessary  to  keep  him  in  bed ;  in 
spite  of  the  severity  of  the  onset,  he  made  a  good  recovery, 
and  was  well  by  January.  In  another  case,  however,  an 
out-]Datient  at  the  London  Hospital,  the  patient  was 
enabled  to  pursue  his  labour  in  the  brickfield  throughout 
the  attack. 

177.  Etiology. — Of  recorded  cases,  that  I  have  been 
able  to  collect,  the  proportion  of  males  io  females  is  as  ten 
to  one.  This  disproportion,  however,  is  less  marked 
among  children  than  adults,  since  under  the  age  of  fifteen 
the  number  of  male  cases  to  females  is  about  four  to  one. 
The  ages  of  the  patients  ranged  from  two  years  to  fifty- four 
years  of  age  ;  I  have  not  been  able  to  find  a  case  in  which 
the  disease  commenced  after  the  fifty- fourth  year.  There 
does  not  appear  to  be  any  greater  liability  to  the  disease 
during  one  period  more  than  another,  in  which  the  disease 
has  been  noticed.  The  cases  reported  by  physicians  at- 
tached to  large  general  hospitals,  where  there  is  a  depart- 
ment for  diseases  of  children,  or  who  are  attached  to  a 
children's  hospital,  naturally  show  a  preponderance  be- 
tween the  age  of  two  and  ten  years ;  whilst  in  the  cases 
reported  by  physicians  attached  to  hospitals  in  which 
there  is  no  special  department,  or  where  the  hospital  is 
near  one  specially  devoted  to  children's  complaints,  the 
adult  cases  are  more  considerable.  If  there  is  any  pre- 
ponderance at  all,  it  is,  as  Dr.  Stephen  Mackenzie  has 
stated,  on  the  side  of  young  adult  males.  Dr.  Saundby 
{Med.  Times,  May,  1880)  has  recorded  an  instance  in  which 
the  disease  was  hereditary.  Among  the  chief  predisposing 
causes  malaria  stands  foremost  on  the  list.     Long  before 

NN 


546  DISEASES    OF    THE    KIDKEY. 

the  clinical  characters  of  the  disease  were  fully  recognized, 
Prout  described  an  intermittent  form  of  haematuria  depen- 
dent upon  ague.  In  about  sixty  per  cent,  of  the  collected 
cases  there  was  either  a  history  of  previous  malarial 
attacks,  or  else  the  patient  had  been  placed  in  circum- 
stances in  -which  he  might  have  been  exposed  to  the 
malarial  influence,  for  it  does  not  follow  that  there  should 
be  any  declared  outbreak  of  intermittent  fever.  One  of 
my  patients  had  never  suffered  from  ague,  but  eighteen 
years  previously  he  had  worked  in  the  marshes  between 
Arundel  and  Portsmouth  where  ague  is  known,  and  in 
another  patient  the  disease  declared  itself  immediately 
after  a  sojourn  in  the  South  of  France,  and  a  recurrence 
took  place  after  visiting  the  same  district  a  second  time. 
Syphilis  is  said  to  play  an  important  part  in  the  etiology  of 
the  disease,  certainly  in  a  considerable  number  of  the 
recorded  cases  a  history  of  syphilis  has  been  established. 

The  disease  occurs  not  infrequently  in  individuals  liable 
to  rheumatism.  In  the  interesting  cases  recorded  by 
Graves,  in  which  articular  rheumatism  was  followed  by 
jaundice  and  urticaria,  it  is  not  improbable  that  hsemo- 
globinuria  might  have  been  present,  the  dark  colour  of 
the  icteric  urine  masking  the  blood  colouring  matter. 
This  of  course  is  only  conjecture,  still  the  clinical  con- 
nexion, jaundice  and  urticaria,  suggests  it,  and  the  pos- 
sibihty  should  be  kept  in  mind.  Among  the  exciting 
causes,  exposure  to  cold  must  be  reckoned  the  chief, 
for  this  reason  the  disease  is  more  frequently  observed  in 
winter  than  in  summer.  It  is  extraordinary  how  slight  a 
chill  will  often  provoke  it,  such  as  sprinkling  a  few  drops 
of  cold  water  on  the  exposed  skin.  The  disease  has  been 
known  to  follow  directly  on  prolonged  and  severe  muscu- 
lar effort  and  strain,  as  after  long  marches,  lifting  weights, 
or  a  long  day  in  the  hunting  field.      I  am  not  aware  of 


HEMOGLOBINURIA.  547 

any  case  originating  from  psychical  causes,  but  tliese  un- 
doubtedly wiU  induce  a  paroxysm  when  the  disease  is 
established.  Among  the  etiological  connections  of  this 
disorder,  must  be  mentioned  Kaynaud's  disease,  which 
consists  in  a  symmetrical  lividity  of  the  extremities,  often 
proceeding  to  gangrene.  In  a  well  marked  instance  of  this 
disease  that  came  under  my  observation  at  the  London  Hos- 
pital, the  hands  when  exposed  first  became  somewhat  red 
and  swollen,  and  then  shortly  became  icy  cold  and  livid, 
the  deep  purplish  jpatches  on  one  hand  corresponding  very 
closely  in  extent  to  those  on  the  other.  In  this  disease 
occasional  discharges  of  urine  containing  hemoglobin,  and 
but  few  rod  blood  corpuscles  have  been  noticed.  The 
transitory  albuminuria  occasionally  observed  after  cold 
bathing  is  probably  an  allied,  if  not  actually  a  minor, 
manifestation  of  paroxysmal  hsemoglobinuria ;  in  some  of 
these  cases  hsematuria  occasionally  occurs  as  well.  On 
the  other  hand,  the  dissolution  and  destruction  of  blood 
corpuscles  which  occur  in  certain  diseases,  such  as  scurvy 
and  purpura,  in  septic  conditions,  and  also  after  the  in- 
troduction of  certain  poisonous  substances,  such  as  Dr. 
Dreschfeld's  case  of  chlorate  of  potash  poisoning,  can 
hardly  be  considered  to  be  even  remotely  allied  to  true 
hsemoglobinuria.  Since  in  these  cases  the  elimination  of 
the  colouring  matter  is  continuous,  and  the  extraordinary 
paroxysmal  character  of  the  disorder  is  entirely  absent. 

178.  Pathology. — One  fact  is  established,  viz.,  that  in 
this  disease  the  blood  corpuscles  have  undergone  dissolu- 
tion. The  unsettled  questions  are  the  place  of  tlieir  dissolu- 
tion, and  the  pathological  causes  at  work  to  produce  it. 

Experiments  have  been  made  on  the  living  body  with 
the  view  of  destroying  the  red  blood  corpuscles  and  giving 
rise  to  hsemoglobinuria.  The  substances  employed  were 
glycerine,  pyrogallic   acid,   and  toluylendiamin,   and   all 

nn2 


548  DISEASES    OF    THE    KIDNEY. 

induced  more  or  less  marked  hsemoglobinuria.  Glycerine 
withdraws  the  haemoglobin  and  causes  its  solution  in  the 
plasma,  but  does  not  give  rise  to  jaundice.  Toluylen- 
diamin,  on  the  other  hand,  breaks  up  the  corpuscles  so 
that  the  blood  becomes  filled  with  coloured  granules, 
which  accumulate  in  the  liver,  spleen,  and  in  the  kidneys  ; 
but  unlike  what  occurs  with  glycerine,  no  hamoglohin  is 
held  in  solution,  and  jaundice  occurs.  Pyrogallic  acid  has 
an  action  intermediate  between  the  two,  extracting  haemo- 
globin and  causing  slight  jaundice.  The  results  of  these 
experiments  closely  correspond  with  our  clinical  experience, 
viz.,  that  there  are  cases  in  which  we  have  evidence  of 
corpuscular  destruction,  and  others  in  which  we  have  none ; 
again,  cases  in  which  jaundice  is  present,  others  in  which 
it  is  absent.  This  would  make  it  appear  probable  that 
two  forms  of  the  disease  exist : — (1)  in  which  an  extrac- 
tion of  haemoglobin  takes  place  in  the  blood  and  the 
colouring  matter  is  eliminated  with  the  urine ;  (2)  in 
which  destruction  of  blood  corpuscles  takes  place  in  the 
liver,  spleen,  and  kidneys. 

An  examination  of  the  blood  in  this  disease  shows  in 
some  cases  that  hemoglobin  is  dissolved  into  the  serum, 
which  acquires  a  tint  varying  from  a  straw  to  a  ruby-red ; 
in  others,  no  change  has  been  observed,  except  an  in- 
crease of  white  corpuscles.  In  the  cases  in  which  the 
serum  was  found  tinted,  alterations  of  the  red  blood  cor- 
puscles were  generally  noticed.  Thus  they  are  paler  than 
natural,  there  is  an  alteration  in  their  colour,  and  the 
tendency  to  rouleaux  formation  disappears.  Some  of  the 
corpuscles  are  quite  devoid  of  contour  (phantom  corpuscles), 
whilst  others  are  so  altered  in  shape  as  to  become  three- 
cornered,  oval,  and  spindle-shaped.  In  addition  to  these 
changes,  blood  flakes  may  also  sometimes  be  observed. 
Boas  (Deutsch.  Archiv  f.  Klin,  Med.,  1883),  who  artificially 


HiEMOGLOBINUBU.  '  549 

induced  attacks  in  patients  suffering  from  the  disease,  con- 
cludes that  in  many  cases  the  dissolution  of  the  red  blood 
corpuscles  takes  place  only  in  the  part  exposed  to  cold. 

The  post-mortem  appearances  of  those  who  have  suffered 
from  the  disease,  or  in  animals  in  which  it  has  been  in- 
duced, generally  reveal  a  certain  degree  of  nephritis.  The 
inflammation  is  most  evident  around  the  glomeruli.  In  the 
artificially  induced  disease  in  animals,  fatty  degeneration 
of  the  renal  epithelium  occurs,  sometimes  the  nephritis  is 
of  such  an  extreme  kind  that  there  are  haemorrhages  into 
the  tubules.  The  liver,  in  the  experimental  cases,  also 
showed  considerable  fatty  changes,  and  in  those  cases 
where  jaundice  was  a  prominent  feature  the  hepatic  cells 
were  laden  with  bile  pigment,  and  the  products  of  blood  dis- 
integration, there  being  further,  an  infiltration  of  round 
cells  around  the  hepatic  and  sub-lobular  veins.  Dr. 
Afanassieu,  from  whoso  account  much  of  the  preceding 
is  taken,  describes  the  renal  lesions  as  hsemoglobinuric 
glomerulo-nephritis,  which  may  pass  eventually  into  an 
interstitial  nephritis,  whilst  the  condition  of  the  liver  he 
considers  to  be  caused  by  interstitial  inflammation,  in- 
duced by  hsemoheptogenous  jaundice.  The  haemoglobin 
or  methsemoglobin,  whether  in  granules,  or  in  solution,  is 
excreted  at  the  glomeruli,  in  this  respect  differing  from 
the  elimination  of  the  formed  products  of  corpuscular  de- 
struction, brought  about  by  poisonous  substances  as  in 
Dr.  Dreschfeld's  case  {oxi.  cit.),  which  are  eliminated  by 
the  tubular  epithelium. 

From  the  foregoing  facts  we  venture  to  infer  that  the 
disease  exists  in  two  forms  : — (1)  in  which  the  haemo- 
globin is  simply  dissolved  out  of  the  blood  corpuscles,  and 
that  in  this  form  of  the  disease,  in  each  attack,  the  dis- 
solution takes  place  chiefly  in  the  parts  exposed  to  cold  ; 
in  this  form,  jaundice  is  not  well  marked,  nor  do  pig- 


550  DISEASES    OF    THE    KIDKEY. 

mented  casts  appear  in  the  urine ;  (2)  a  more  severe  form, 
in  which  the  dissolution  is  general,  and  probably  attended 
with  some  destruction  of  red  corpuscles  in  the  liver, 
spleen,  and  even  in  the  kidneys  ;  in  these  cases  the  icteric 
tint  is  well  marked,  and  casts  containing  crystals  of 
haemoglobin,  bile  crystals,  and  pigmented  granules  of  dis- 
integrated blood  corpuscles  will  be  distinctly  visible.  In 
most,  if  not  in  all  cases,  the  elimination  of  the  haemo- 
globin occasions  a  certain  degree  of  irritation,  if  not  actual 
glomerulo-nephritis,  which  accounts  for  the  presence  of 
serum  albumin  in  the  paroxysmal  urine,  and  of  which 
traces  may  occasionally  be  found  some  time  after.  Should 
the  attacks  be  frequent,  or  the  disease  prolonged,  inter- 
stitial changes  may  ultimately  result. 

With  regard  to  the  conditions  that  induce  the  attack  we 
are  still  in  the  dark,  though  there  are  many  circumstances 
such  as  the  peculiar  chills,  and  the  accompanying  urti- 
caria, that  suggest  a  neurosal  origin,  probably  an  exag- 
gerated sensibiHty  of  the  reflex  nervous  system.  It  may 
be  as  some  have  suggested,  that  peripheral  stimulation 
causes  irritability  of  the  vaso- motor  centre,  and  in  turn 
this  causes  local  asphyxia  in  the  part  stimulated,  under 
which  condition  the  red  corpuscles  part  with  the  haemo- 
globin. Thus,  Murri  (Revista  Clinica  di  Bologna,  1880) 
holds  the  essence  of  the  disease  to  be  due  to  an  increased 
irritability  of  the  vaso-motor  reflex  centre,  and  the  forma- 
tion, owing  to  disorder  of  the  blood  forming  organs,  of 
corpuscles  unable  to  withstand  the  influence  of  cold  or  of 
carbonic  acid. 

179.  Treatment. — After  the  occurrence  of  a  few 
paroxysms  the  disease  may  disappear  entirely,  more  usually 
the  disease  recurs  irregularly  for  a  considerable  number  of 
years.  Although  no  patient  can  be  said  to  have  actually 
died  of  the  disease,  yet  undoubtedly  it  is  a  serious  compli- 


HiEMOGLOBINURIA.  551 

cation  should  any  intercurrent  affection  supervene,  especi- 
ally if  of  an  acute  character.  Pneumonia  seems  to  be  the 
most  frequent  termination  of  those  cases  which  have  run 
a  protracted  course,  and  is  usually  preceded  and  accom- 
panied by  chronic  nephritis. 

As  cold  is  the  chief  exciting  agent  in  the  production  of 
the  disease,  so  avoidance  of  chills  of  all  kinds  is  the  best 
prophylactic  measure  we  can  employ  to  prevent  the  recur- 
rence of  the  paroxysmal  attacks.  The  patient  should  be 
clothed  in  flannel,  wear  woolen  gloves  and  stockings,  and 
tightly  fitting  drawers.  He  should  be  careful  to  avoid 
exposing  himself  to  cold  whilst  dressing  and  undressing. 
It  is  astonishing  how  hypersensitive  some  of  these  patients 
are  to  the  slightest  change  of  temperature  ;  in  one  of  my 
patients  the  act  of  getting  out  of  bed,  although  the  room 
was  well  warmed  with  a  fire,  and  the  weather  was  not 
cold,  brought  on  a  paroxysm.  Dr.  Barlow  has  suggested 
that  this  over  sensitiveness  may  be  overcome  by  gradually 
habituating  the  patient  to  cold,  and  mentions  the  case  of  a 
child  who  was  much  benefitted  by  being  washed  in  cold 
instead  of  hot  water.  I  would  not,  however,  recommend 
this  practice  in  all  cases,  especially  in  those  in  which  the 
urine  remains  albuminous  between  the  paroxysms,  for  fear 
of  increasing  the  renal  hypersemia.  It  may  be  successfully 
tried,  however,  when  the  disease  remits,  and  the  patient 
for  a  time  regains  his  usual  health,  so  that  the  cutaneous 
nerves  may  be  rendered  less  sensitive  to  cold,  should  the 
tendency  recur.  The  best  plan  is  to  commence  with  a 
douche  so  regulated  that  at  first  hot  water  is  poured  over 
the  patient,  which  gradually  becomes  colder,  till  a  tem- 
perature of  about  40°  F.  is  reached.  I  have  found  warm 
(95°  F.)  sea  bathing,  or  sea  salt,  distinctly  beneficial  in 
two  cases  under  my  care,  the  salt  seemed  to  stimulate  the 
skin  and  gradually  render  it  less  sensitive. 


552  DISEASES    OF    THE    KIDNEY. 

As  regards  general  treatment  the  universal  consensus  of 
opinion  is  in  favour  of  quinine ;  even  in  those  cases  in 
which  there  is  no  evidence  of  malaria  it  is  of  decided 
value.  For  in  cases  in  which  it  fails  to  control  the 
paroxysms  or  cut  short  the  disease,  it  will  generally  im- 
prove the  patient's  condition.  Next  to  quinine  in  my 
opinion,  comes  arsenic.  Under  its  administration  the 
blood  corpuscles,  if  previously  affected,  acquire  a  better 
colour,  and  appear  less  translucent.  Although  it  has  not 
the  same  power  that  quinine  often  has  in  controlling  the 
paroxysms,  yet  I  think  it  makes  the  cure  more  complete. 
The  patient,  whose  case  I  recorded  in  the  Lancet,  Nov. 
1883,  had  previously  suffered  during  the  spring  months 
of  four  successive  years  from  hsemoglobinuria ;  when  I  saw 
him  in  March  1883,  I  put  him  on  arsenic,  three  drops 
three  times  a  day,  and  a  daUy  four-grain  dose  of  quinine. 
This  had  no  apparent  effect  till  about  the  middle  of  April, 
when  the  weather  became  warmer,  when  he  made  what 
may  be  considered  a  sudden  recovery.  I  kept  on  the 
arsenic  for  some  time  longer.  He  missed  his  usual  attack 
in  the  ensuing  spring  of  1884,  he  also  stated  that  none  of 
the  preceding  attacks  had  yielded  so  quickly,  and  that  he 
had  never  before  got  rid  of  his  complaint  till  the  middle  of 
summer.  My  practice  is  therefore  to  give  one  good  dose 
of  quinine,  four  to  five  grains  once  daily,  and  a  mixture 
containing  three  or  four  drops  of  liquor  arsenicaHs,  and 
ten  grains  of  ammonium  chloride  of  iron,  thrice  daily  after 
meals.  If  there  is  any  history  of  syphihs,  I  add  to  this 
mixture  ten  grains  of  iodide  of  potassium.  The  diet 
should  be  light  and  easy  of  digestion.  In  a  case  that  has 
now  been  frequently  under  my  observation,  the  patient 
finds  that  when  he  attends  particularly  to  this  point  his 
urine  remains  clear  for  long  periods  together,  whilst  an 
attack  of  indigestion  from  imprudence  will  at  once  tinge 


HEMOGLOBINURIA.  553 

his  urine  with  blood.  The  diet,  which  should  be  chiefly 
farinaceous,  should  be  similar  to  that  given  at  p.  263. 
Should  the  disease  be  accompanied  by  marked  manifes- 
tations of  pyrexia,  the  patient  must  be  kept  in  bed,  other- 
wise he  may  go  about  as  usual,  keeping  quiet,  however, 
for  some  hours  during  and  after  the  occurrence  of  a 
paroxysm. 


554  DISEASES    OF    THE    KIDNEY. 


APPENDIX  I. 

Quantitative  Analysis. 

1.  Urea.  {LieUg's  method). — "When  a  solution  of  mer- 
curic nitrate  is  added  to  a  solution  of  urea  an  insoluble 
compound  of  urea  and  mercury  is  formed.  If  we  continue 
to  add  the  mercuric  solution,  as  long  as  the  precipitate  is 
formed,  a  point  is  reached,  when,  on  addition  of  sodium 
carbonate,  a  yeUow  colour  is  produced  by  the  appearance 
of  hydrated  oxide  of  mercury.  This  indicates  that  all  the 
urea  has  been  precipitated  by  the  mercuric  solution. 

Solutions  required. — 1.  Mercuric  nitrate  solution,  one  cubic  centimetre 
of  which  is  equivalent  to  O'Ol  grm.  of  urea. 

2.  Baryta  solution,  consisting  of  two  vols,  of  baric  hydrate,  and  one 
vol.  baric  nitrate,  to  precipitate  phosphates  and  sulphates. 

3.  Sodic  carbonate  solution,  placed  on  a  white  filter  paper  to  indicate 
completion  of  the  process. 

Process. — Take  30  c.c.  of  urine,  and  add  to  it  30  c.c.  of  the  baryta  solu- 
tion. Mix  thoroughly  and  filter.  Now  carefully  measure  off  by  means 
of  a  pipette,  21)  c.c.  of  the  filtrate;  this  of  course  contains  10  c.c.  of  urine. 
Place  this  in  a  glass  beaker,  and  then  from  a  Mohr's  burette,  add  at  first 
5  c.c.  of  the  mercuric  nitrate  solution,  stirring  the  mixture,  and  placing 
a  drop  on  the  sodic  carbonate  test-paper.  If  no  reaction  occurs,  then 
add  a  cubic  centimetre  at  a  time  from  the  burette,  till  a  yellow  stain 
appears.  The  number  of  cubic  centimetres  employed  gives  the  amount 
of  urea  in  10  c.c.  of  urine.  Then  if  we  know  the  amount  of  the  twenty- 
four  hours'  urine,  the  diurnal  excretion  of  urea  can  readily  be  made ; 
thus,  the  patient  has  passed  2110  c.c.  of  urine,  and  12  c.c.  of  standard  mer- 

,   ..  ,   ,,       2110  X  (-01  X  12)        „..,„  , 

cunc  solution  were  used,  then ^     '  =  25  32  grms.  ot  urea. 

10  c.c. 

Correction.— Bnt  as  the  urine  contains  sodium  chloride,  and  as  this  ia 

likewise  precipitated  by  mercuric  nitrate,  we  must  make  a  correction  for 

this.     This  is    done,   either  by  determining    the  amount  of   sodium 

chloride  separately  as  by  process  5,  and  making  the  correction  directly 


APPENDIX.  555 

from  this;  or  by  adding  a  concentrated  solution  of  silver  nitrate  to 
the  urine,  from  which  the  phosphates  and  sulphates  have  been  pre- 
cipitated, till  no  further  precipitation  of  silver  chloride  takes  place;  then 
filter  and  proceed  to  add  the  mercuric  solution.  In  ordinary  cases,  how- 
ever, (excepting  pneumonia  and  rheumatic  fever)  it  is  sufficient  to  deduct 
1"5  to  2  c.c.  from  the  total  c.c.  of  mercuric  nitrate  employed  for  the  pre- 
cipitation of  the  insoluble  compound  of  urea  and  mercury. 

2.  Hippuric  Acid. — The  process  consists  of  separating 
the  uric  acid  from  the  hippuric  acid,  and  crystallising  out 
the  latter  from  its  solution,  and  collecting  and  weighing 
the  deposited  crystals. 

Process. — Evaporate  lOOD  c.c.  of  urine  to  dryness.  Triturate  with  baric 
sulphate,  add  60  c.c.  of  hydrochloric  acid,  and  then  exhaust  with  alcohol. 
Neutralize  the  acid  alcoholic  extract  with  soda-ley.  Evaporate  to  a 
syrupy  consistence,  adding  a  small  quantity  of  oxalic  acid.  Then  dry  in 
a  water  bath.  Exhaust  dry  mass  with  ether  containing  twenty  per  cent, 
of  alcohol.  Evaporate  the  ethereal  alcoholic  solution,  and  treat  the 
crystalline  residue  with  warm  milk  of  lime.  Filter.  Evaporate  filtrate 
to  small  volume,  add  hydrochloric  acid.  The  hippuric  acid  now  crystal- 
lises out,  the  crystals  are  collected  on  a  weighed  filter,  washed,  dried, 
and  weighed ;  the  weight  gives  the  amount  of  hippuric  acid  in  amount  of 
urine  examined. 

3.  Phosphoric  Acid. — An  acid  solution  of  uranic 
nitrate  added  to  a  solution  of  phosphoric  acid  is  decom- 
posed, and  a  precipitate  of  uranic  phosphate  is  thrown 
down.  Uranic  nitrate  gives  a  reddish  stain  when  dropped 
on  ferrocyanide  of  potassium  test-paper,  but. uranic  phos- 
phate does  not  give  a  coloration.  As  long,  therefore,  as 
the  uranic  phosphate  is  precipitated  on  the  addition  of 
uranic  nitrate  no  brown  stain  will  be  given  to  a  ferro- 
cyanide of  potassium  test-paper,  but  as  soon  as  a  precipitate 
ceases  to  be  formed  the  coloration  is  given,  because  then 
free  uranic  nitrate  appears  in  the  mixture.  It  is  on  this 
fact  that  the  process  for  estimating  phosphoric  acid  by 
means  of  uranic  nitrate  is  based. 


656  DISEASES    OF    THE    KIDNEY. 

Solutions  required. — 1.  Uranic  nitrate  solution,  one  cubic  centimetre 
of  which  is  equivalent  to  '005  grm.  of  phosphoric  acid. 

2.  Sodic  acetate  solution  to  ensure  precipitation  of  uranic  phosphate. 

3.  Potassic  ferroeyanide  solution  to  moisten  indicating  test-paper. 
Process. — Take  50  c.c.  of  urine,  add  to  them  5  c.c.  of  acetate  solution, 

and  warm  the  mixture.  Then  from  a  burette  add  a  cubic  centimetre  at  a 
time  of  uranic  nitrate  solution,  each  time  stirring  with  glass  rod,  and 
placing  a  drop  on  the  test-paper  moistened  with  ferroeyanide  solution. 
Continue  till  with  the  last  addition  a  brownish  stain  developes  on  the 
paper.  The  number  of  c.c.  from  the  burette  used  to  effect  this,  repre- 
sent the  amount  of  phosphoric  acid  in  50  c.c.  of  urine.  Then  if  we  know 
the  amount  of  urine  passed  in  twenty-four  hours,  we  can  readily  cal- 
culate the  diurnal  elimination ;  thus,  the  patient  has  passed  1450  c.c. 
of  urine,  and  the  amount  of  urauic  solution  employed  is  16  c.c.  then 

1450x(16x-005)       „.„„  f   u       T,     •        -J 
^ •'  =  2  32  grms.  oi  phosphoric  acid. 

Separate  determination  of  phosphoric  acid  combined  with  alkaline 
and  earthy  bases  respectively.  The  foregoing  process  gives  us  the  total 
phosphoric  acid  in  urine,  but  does  not  tell  us  in  what  proportion  it  is 
combined  with  the  different  bases.  To  ascertain  this,  we  take  50  c.c.  of 
urine,  and  render  it  strongly  alkaline  with  ammonia.  Set  aside  ihe  mix- 
ture for  twelve  hours.  Collect  the  precipitated  phosphate  upon  a  filter, 
and  wash  with  liquor  ammonise.  Then  dissolve  the  precipitate  with  a 
little  dilute  acetic  acid.  Place  the  acid  solution  in  a  small  beaker,  add  5 
c.c.  of  sodic  acetate  solution,  add  distilled  water  up  to  50  c.c,  and  then 
proceed  to  add  the  uranic  nitrate  as  before.  Now  in  the  1450  c.c,  instead 
of  using  16  c.c.  of  the  standard,  we  shall  find  that  less  has  been  used, 

say  6  c.c;  then, — ^  =  0'87  grm.  of  phosphoric  acid  com- 
bined with  lime  and  magnesia.  And  as  we  found  the  total  phosphoric 
acid  by  the  previous  estimation  was  2'32  grms.,  and  as  we  have  now 
found  the  phosphoric  acid  in  combination  with  the  earthy  bases  to  be 
0'87  grm.;  then  the  difference  between  these  two  represents  the  amount 
of  phosphoric  acid  in  combination  with  the   alkaline  bases,  viz.  1'45  grm. 

4.  Sulphuric  Acid  is  estimated  by  adding  a  solution 
of  baric  chloride  to  an  acid  solution  of  urine,  till  a  precipi- 
tate is  no  longer  formed. 

Solution  required. — Baric  chloride  solution,  one  cubic  centimetre  of 
which  is  equivalent  to  O'Ol  grm.  of  sulphuric  acid. 

Process. — Add  to  25  c.c.  of  urine  five  drops  of  HCl,  and  warm  the  solu- 
tion.    Now  add  from  a  burette  the  standard  solution,  one  c.c.  at  a  time. 


APPENDIX.  557 

till  a  precipitate  is  no  longer  formed.  The  number  of  c.c.  used  to  effect 
this,  represents  the  amount  of  sulphuric  acid  in  25  c.c.  of  urine.  Now  if 
the  patient  passes  1450  c.c.  of  urine,  and  5  c.c.  of  baric  chloride  has 
been  used  ;  then  —     ><(  01x5)  _  ^.^  ^^^^^  ^^  sulphuric  acid  eliminated 

25 
in  twenty-four  hours. 

5.  Hydrochloric  Acid. — When  nitrate  of  silver  is 
dropped  into  a  neutral  solution  of  sodium  chloride  and 
neutral  potassium  chromate,  the  chlorine  is  thrown  down 
in  the  form  of  chloride  of  silver.  When  the  whole  of 
the  chlorine  is  thrown  down,  then  it  is  converted  into 
chromate  of  silver  which  gives  the  mixture  a  permanent 
red  colour.     When  this  occurs  the  process  is  complete. 

Solutions  required. — 1.  Nitrate  of  silver  solution,  1  c.c.  =  "01  grm.  of 
sodium  chloride,  or  '006  grm.  of  hydrochloric  acid. 

2.  Yellow  potassium  chromate  solution,  saturated. 

Process. — Collect  the  urine  for  twenty-four  hours,  carefully  measure, 
remove  albumin  if  present.  Filter  a  portion  of  this  urine  and  measure 
off,  by  means  of  a  pipette,  10  c.c.  into  a  small  beaker,  and  add  a  few 
drops  of  sodium  carbonate  solution,  to  render  it  neutral,  and  dilute  with 
distilled  water  up  to  100  c.c.  A  few  drops  of  potassium  chromate  solu- 
tion are  now  added  and  a  few  c.c.  of  the  standard  solution  of  silver 
nitrate  run  into  the  mixture  from  a  Mohr's  burette ;  agitate.  Continue 
to  add  a  c.c.  or  so  of  the  standard  solution  till  a  red  colour  appears  when 
the  mixture  is  agitated  (red  silver  chromate).  Now  since  1  c.c.  of  the 
silver  nitrate  solution  is  equal  to  *006  grm.  of  hydrochloric  acid,  there- 
fore if  6  c.c.  of  silver  nitrate  be  used,  the  10  c.c.  of  urine  will  contain 
'036  grm.  of  hydrochloric  acid,  and  if  1500  c.c  of  urine  be  passed  in  the 

twenty-four  hours,  then ■  =  5*4  grms.  of  hydrochloric  acid. 

As  the  colouring  matter  of  the  urine,  if  in  excess,  interferes  with  the 
reaction,  in  these  cases  it  is  necessary  to  evaporate  the  urine  and  in- 
cinerate the  ash,  dissolve  this  in  water,  and  then  proceed  as  above. 

6.  Albumin. — The  albumin  is  coagulated  by  means  of 
heat,  collected,  dried  and  weighed. 

Process. — Take  100  cubic  centimetres  of  urine,  place  it  in  a  glass  beaker, 
and  add  two  or  three  drops  of  strong  acetic  acid,  to  render  it  slightly  acid, 
and  add  distilled  water  to  bring  the  measure  up  to  200  c.c.     Place  the 


658  DISEASES    OF    THE    KIDNEY. 

beaker  in  a  water-bath,  100°  C,  for  about  half  an  hour,  frequently  stir- 
ring to  prevent  clotting,  then  set  aside  to  subside.  When  the  coagula 
have  fallen  to  the  bottom  of  the  vessel  decant  the  supernatant  fluid  into 
another  vessel,  and  place  the  coagulated  material  on  a  filter  previously 
dried  and  weighed,  carefully  removing  any  portion  that  may  adhere  to 
the  glass  vnth  a  feather  to  the  filter.  Set  aside  to  drain,  add  from  time 
to  time  any  portion  of  coagula  that  may  be  deposited  from  the  super- 
natant  fluid  that  was  decanted. '  When  every  visible  fragment  of  coagula 
has  been  transferred  to  the  filter,  place  it  in  the  hot-air  bath  and  cau- 
tiously dry.  When  it  has  been  in  the  air-bath  some  hours  withdraw, 
cool,  and  weigh,  and  repeat  this  process  till  it  ceases  to  lose  weight. 
When  it  does,  deduct  the  original  weight  of  the  filter  from  the  amount, 
and  the  difierence  will  give  the  weight  of  albumin  in  lOU  cubic  centi- 
metres of  urine.  Thus,  the  weight  of  the  filter,  previously  ascertained, 
is  0"175  grm.,  and  the  weight  of  the  filter  with  the  albumin  after  drying  is 
()"598  grm.;  then  "598 — '175  =  '423  grm.,  the  weight  of  albumin  in 
100  c.c.  of  urine  ;  and  if  the  patient  pass  1100  c.c.  of  urine  in  -twenty-four 
hours,  then  the  amount  of  albumin  discharged  from  the  system  in  the  day 

.,, ,     1100  X  -423       ..;.-, 

will  be =  4"6o3  grms. 

100 

7.  Sugar. — Solutions  of  glucose  possess  the  property  of 
reducing  cupric  salts  to  cuprous  oxide,  in  the  presence  of 
alkalies,  p.  119.  It  is  upon  this'  property  that  the  quanti- 
tative estimation  of  sugar  is  based. 

Solutions  required. — 1.  Cupric  sulphate  solution,  (34'63  grms.  of  cupric 
sulphate  and  distilled  water  up  to  one  litre),  one  cubic  centimetre  of 
which  is  equivalent  to  "005  of  glucose. 

2.  Alkaline  tartrate  solution,  (potassic  hydrate  80 grms.,  sodio  potassic 
tartrate  173  grms.,  and  distilled  water  up  to  one  litre). 

Process. — Measure  off  10  c.c.  of  the  collected  urine  of  twenty-four  hours, 
remove  albumin  if  present,  and  dilute  it  with  distilled  water  up  to  200 
c.c.     Charge  a  burette  with  this  diluted  urine. 

Into  a  porcelain  basin,  or  a  glass  flask  suspended  to  the  burette,  con- 
taining 50  c.c.  of  distilled  water,  measure  off  10  c.c.  of  standard  copper 
solution,  and  10  c.c.  of  alkaline  tartrate  solution,  and  gradually  bring 
the  mixture  to  the  boiling  point. 

When  the  alkaline  copper  solution  has  reached  the  boiling  point,  a  few 
drops  of  the  dilute  urine  are  run  into  it  from  the  burette;  at  first  the 
addition  only  makes  the  copper  solution  turbid  with  a  greenish-red  pre- 
cipitate, which  subsequently  on  the  further  addition  of  urine,  acquires  a 
deeper  red,  and  settles  readily  at  the  bottom  of  the  porcelain  vessel. 


APPENDIX.  559 

After  each  addition  of  uriae,  the  precipitate  should  be  allowed  to  settle 
and  the  vessel  slightly  tilted  so  as  to  observe  the  colour  of  the  super- 
natant fluid;  when  this  becomes  perfectly  colourless,  the  process  is  com- 
plete and  the  estimation  can  be  made  as  follows : — 

Suppose  that  30  cubic  centimetres  of  dilute  urine  have  been  employed, 
and  as  the  urine  was  in  the  first  instance  diluted  to  50  of  its  volume,  these 
80  c.c.  are  equivalent  to  1'5  c.c.  of  the  diabetic  urine.  And  as  1  c.c.  of 
the  cupric  solution  =  '005  grm.  of  sugar,  and  10  c.c.  of  the  solution  was 
used,  it  is  clear  that  1'5  c.c.  of  diabetic  urine  contains  '05  grm.  of  sugar. 
Then  if  the  patient  passed  4110  c.c.  of  urine  in  the  twenty-four  hours, 

=  137  grms.  of  sugar,  or  the  same  result  is  more  readily  ob« 

1"5 

tained  by  dividing  the  twenty-four  hours  urine  by  the  number  of  centi- 
meters of  dilute  urine  used  from  the  burette  thus  ~ —  =  137  grms. 


560  DISEASES    OF    THE    KIDNEY. 


APPENDIX  IT. 

Diet  fok  Diabetic  Cases. 

The  Dietetic  Treatment  in  diabetes  consists :  1 . 
In  cutting  off  every  article  of  diet  whicli  contains  starch  or 
sugar  in  any  form ;  2.  In  replacing  such  articles  with 
some  kind  of  substitute,  and  also  in  rendering  the  food 
that  can  be  taken  as  palatable,  nutritious,  and  varied  as 
possible. 

To  fulfil  the  first  indication,  the  medical  attendant 
should  draw  up  and  give  the  patient  a  list  of  those  articles 
of  diet  he  is  to  avoid,  and  those  articles  of  which  he  may 
partake,  thus : — 

To  avoid. — Milk  (except  very  small  quantities  for  cooking  purposes). 
The  liver  of  all  animals  (as  the  liver  of  oysters  and  all  mollusca  is  large, 
and  abounds  in  glycogen,  these  animals  must  be  forbidden)  so  also  the 
interior  of  crabs,  lobsters,  etc.  Bread,  biscuits,  rusks,  toast,  farinace- 
ous vegetables,  such  as  potatoes,  Jerusalem  artichokes,  rice,  oatmeal, 
corn-flour,  sago,  tapioca,  arrowroot,  etc.  Saccharine  vegetables, 
turnips,  carrots,  parsnips,  green  peas,  French  beans,  beet-root,  asparagus, 
tomatoes.  Blanched  vegetables  of  every  sort  as  celery,  sea-kale,  endive, 
radishes,  also  the  stalks  and  white  parts  of  such  vegetables  as  cabbage, 
lettuce,  broccoli,  etc.  Fruits  of  all  kinds.  Jams,  syrups,  sugars.  Cer- 
tain condiments,  such  as  Chutnee  and  sweet  pickles.  Cocoa,  chocolate. 
Liquors,  sweet  wines. 

May  taJce. — Meat,  fish,  poultry,  game,  butter,  bacon,  ham,  eggs.  Bread 
and  biscuits,  made  with  prepared  gluten  bran,  or  almond  flour.  Green 
vegetables,  summer  cabbage,  turnip  tops,  spinach,  broccoli  tops,  water- 
cresses,  mustard  and  cress,  laver,  sauer  kraut,  the  green  parts  of  lettuce, 
sorrel,  mushrooms.    Nuts  of  various  kinds  (except  chesnuts).    Cheese. 

The  second  indication  is  best  fulfilled  by  varying  the 
dietary  as  much  as  possible,  so  as  to  prevent  monotony, 
and  by  the  greatest  attention  being  paid  to  the  preparation 
and  selection  of  the  food,  so  that  it  may  be  both  palatable 


APPENDIX.  •  561 

and  nutritious,  the  following  hints  from  a  diabetic  patient 
may  prove  serviceable. 

An  egg  beaten  up  in  tea  or  coffee  is  not  a  bad  substitute  for  milk.  The 
most  palatable  form  of  prepared  bread  is  the  gluten  roll  (Bonthron). 
This  cut  in  slices  well  buttered,  goes  very  well  with  potted  meats, 
anchovy  paste,  caviare,  grated  Hambro'  beef.  A  savoury  omelette  (four 
eggs  to  one  table-spoonful  of  milk)  is  often  an  agreeable  change  when  the 
patient  tires  of  "phantom  crusts."  A  list  of  breakfast  dishes  should  be 
drawn  up,  these  should  be  as  varied  as  possible,  thus  fish  one  day, 
kidneys  another,  eggs  and  bacon,  grilled  chicken,  and  so  on.  Sausages, 
since  they  usually  contain  a  considerable  quantity  of  bread  should  not  be 
allowed.  For  lunch,  a  chop,  steak  or  cutlets,  with  watercress  or  salad  ; 
if,  however,  the  patient  has  eaten  solid  meat  for  breakfast,  fish  had  better 
be  served  for  lunch.  At  dinner,  either  a  good  clear  meat  soup,  made  with- 
out vegetables,  but  flavoured  with  herbs ;  or  fish.  The  following  receipt  for 
melted  butter  made  without  flour,  may  be  found  useful.  "Rub  up  the 
yolk  of  a  hard  boiled  egg  with  olive  oil  till  a  rich  paste  is  formed,  add 
two  ounces  of  butter,  and  heat,  gently  stirring;  add  anchovy  sauce, 
capers,  fennel,  chopped  parsley  or  sorrel,  lemon  juice,  etc.,  as  may  be 
required."  A  green  salad  should  always  be  served  with  the  meat,  it  should 
be  mixed  with  plain  oil  and  vinegar,  and  warn  the  cook  against  adding 
sugar.  As  the  number  of  green  vegetables  are  limited  they  should  be 
quite  fresh,  carefully  cooked,  and  well  served,  otherwise  the  patient  be- 
comes disgusted  with  them,  which  is  always  a  misfortune,  since  owing 
to  the  amount  of  animal  food  eaten,  plenty  of  green  stufi'  is  required  to 
keep  the  body  healthy.  It  is  astonishing  in  what  a  diS"erent  number  of 
ways  a  simple  cabbage  may  be  cooked,  so  as  to  make  almost  a  daily 
variety.  If  the  patient  can  be  educated  up  to  saner  kraut,  he  will  find  it 
very  beneficient  to  his  health.  Watercresses  should  be  served  at  every 
meal.  Meat  twice  cooked  should  never  be  served.  Since  sweets  may 
not  be  partaken  of,  savouries  should  follow  the  meat.  Savoury  omelettes, 
caviare,  anchovies,  cheese  fondiis;  sometimes  the  omelettes  may  be  fla- 
voured with  grated  cocoanut,  glycerole  of  orange  peel,  essence  of  vanille, 
almonds,  etc.,  or  a  mixture  of  sherry,  glycerine  and  lemon  juice. 

The  diabetic  patient  should  be  cautioned  against  too  great  indulgence 
of  his  appetite,  he  should  just  satisfy  his  hunger  and  no  more.  A  French 
physician  observed  that  during  the  siege  of  Paris  many  diabetic  patients 
improved,  when  they  could  not  obtain  the  usual  amount  of  animal  food 
they  were  accustomed  to  consume.  "  I  have  found  the  urine  less  sac- 
charine, and  myself  in  better  health  on  a  moderate  diet,  than  when  I 
hare  fully  indulged  my  appetite.  After  a  little  restraint  the  craving  for 
extra  meat  soon  ceases." 

00 


EEFEEENCES. 


Afanassieu.     Haemoglobinuria,  '  Zeit.  f.  klin.  Med.'  Bd.  vi. 

1883. 
AuFEECHT.     Albuminuria,   'Berlin,   klin.  Wocbensclirift/ 

Dec.  12,  1883. 
Bartels.    Diseases  of  tbe  Kidney,  '  Ziemssen's  Cyclope- 
dia' (Eng.  Trans.),  vol.  xv. 
Beale,  Lionel.     '  Kidney  Diseases,  Urinary  Deposits,  &c.' 

3rd  edit. 
Beck,  Marcus.    Consecutive  Nepbritis,  'Eeynolds'  System 

of  Medicine,'  vol.  v. 
Begbie.     'Works,'   edited  by  Dr.  Duckwortb  (New  Syd. 

Soc,  1882). 
Beneke.     *  Zur  Pbys.  und  Patb.  des  Pbospbors.  und  Oxal- 

saure  Kalkes,'  1850. 
Bird,  Golding.     '  Urinary  Deposits,'  5tli  edit. 
Brieger.      Putrefactive  Alkaloids,  '  Bericbte  der  Cbemie 

Gescbicbte,'  1884. 
Bright.     '  Eeports  on  Medical  Cases,'  1827. 
Brunton   and  Power.      Food   Albuminuria,   '  St.  Bartb. 

HosiD.  Eeports,'  vol.  xii. 
Capitan.      '  Eeebercbes  experimentales  et  cHniques  sur  les 

Albuminuries  Transitories,'  1883. 
Carter,  Vandyke.     '  Structure  and  Formation  of  Urinary 

Calcub,'  1873. 
Chateaubourg.     '  Eeebercbes  sur  Talbuminurie  pbysiolo- 

gique,'  1883. 
CoBBOLD.     '  Parasites,'  1879. 


EEFEEENCES.  563 

Davaine.     '  Traite  des  Entozoaires,'  1860. 

D'EspiNE.     Uraemia,  '  Kevue  de  Medicine,'  Sept.  1884. 

Deichmuler  and  Tollens.    Acetone,  '  Annalen  der  Chimie,' 

Bd.  209,  1880. 
Dickinson.     '  Diseases  of  the  Kidneys,'  part  1,  Diabetes  ; 

part  2,  Albuminuria  ;  part  3,  General  Diseases. 
Dreschfeld.     Haemoglobinuria,  '  Trans.  Inter.  Med.  Con- 
gress,' London,  1881. 
Dukes,  Clement.     Albuminuria  in  young  persons,  'Brit. 

Med.  Journal,'  vol.  ii.  1878. 
Ebstein.    Diseases  of  the  Kidney, '  Ziemssen's  Cyclopaedia,' 

(Eng.  Trans.),  vol.  xv. 
Edlessen.     EHmination  of  Phosphoric  Acid,  '  Centralblatt 

f.  d.  Med.  Wissenschaft,'  July,  1878. 
Fehe,  a.     '  Ueber  die  Amyloide  Degeneration  der  Nieren.' 

Bern,  1867. 
FiNLAYsoN.     Albuminuria,  Keport  of  Debate  on,  Glasgow, 

'  Glasgow  Med.  Journal,'  1884. 
Foster.     '  Textbook  of  Physiology,'  3rd  edit. 
Feiedlandee.     Glomerulo-Nephritis,  '  Fortschr.  der  Med., 

vol.  i.  no.  3, 
Feeeichs.     'Die  Bright'sche  Nierenkrankheit,'  1851. 
Feerichs,  F.  T.     Diabetic  Coma,   'Zeit.  f.  klin.  Med.', 

Bd.  vi.  1883. 
Gamgee.     '  Phys.  Chemistry  of  the  Animal  Body.' 
Garrod.     '  Nature  and  Treatment  of  Gout,'  3rd  edit. 
GowERS.     'Atlas  of  Med.  Oijhthalmoscopy,'  2nd  edit. 
Greenfield.    'Atlas  of  Pathology,'  Ease,  1  and  2.    (Xew 

Syd.  Soc.) 
Habeeshon.  'Diseases  of  the  Liver.'  (Lettsomian  Lectures). 
Hamilton.     Albuminuria,  Eeport  of  Debate  on,  Glasgow. 

'  Glasgow  Med.  Journal,'  1884. 
Heldenhain.     Function  of  Eenal  Epithelium,  Hermann's 

'Handbuch  der  Phys.'  Bd.  v.  part  1. 

oo2 


564  DISEASES    OF    THE    KIDNEY; 

Heubner.    Hsemoglobinuria, '  Deutsch.  Arch.  f.  klin.  Med. 

Bd.  xxiii.  1883. 
HoFMEtsTEE.     Peptonuria,  '  Zeit.  f.  Phys.  Chemie,'  Bd.  iv. 

§  260,  and  Bd.  v.  §  75. 
Jaksch,  E.     Peptonuria,  'Zeit.  f.  klin.  Med.'  Bd.  vi.  1883. 
Johnson,  G.     '  Diseases  of  the  Kidneys,'  1852. 
Jones,  Bence.    '  Lectures  on  Pathology  and  Therapeutics,' 

1866. 
Ejener  and  Kelsch.     Malarial  Albuminuria,  '  Archiv.  der 

Phys.'  Feb.  1882. 
Klebs.      Glomerulo-Nephritis,   '  Handb.   d.  Path.   Anat.' 

vol.  i. 
Klein.     Glomerulo-Nephritis,   '  Keports  to  Privy  Council,' 

1876. 
Klein.  Glomerulo-Nephritis, ' Path.  Soc.  Trans.'  vol.  xxviii. 
Lancereaux.     'De  la  Polyurie,'  Paris,  1869. 
Landau.     '  Die  Wanderniere  der  Frauen,'  1881. 
Latham.    '  On  the  Formation  of  Uric  Acid,  &c.'  Cambridge, 

1884. 
Leech.  Glomerulo-Nephritis,  'Brit.  Med.  Jour.'  vol.  i.  1881. 
Le  Nobel.    Diabetic  Coma,  '  Arch.  f.  Exp.  Path.'  Bd.  xviii. 

Heft.  1  and  2. 
Lexjbe.     Functional  Albuminuria,  '  Virch.  Arch.'  79. 
Mackenzie,  S.     Hsemoglobinuria,  'Proc.  Med.  Soc.  Lond.' 

vol.  vii. 
MacMxjnn.     *  The  Spectroscope  in  Medicine,'  1880. 
Mahomed.    Prealbuminuric  stage  of  Nephritis,  '  Koy.  Med. 

Chir.  Trans.'  vol.  Ivii. 
Maixner.      Peptonuria,  'Prager   Vierteljahrsschrift.'  Bd. 

cxliv.,  §  75,  1879. 
Maecet.      'Exp.  Enquiry  into  the  Nutrition  of  Animal 

Tissues.' 
Minkowski.   Diabetic  Coma,  'Arch.  f.  Exp.  Path.'  Bd.  xviii. 

Heft.  2. 


REFERENCES.  565 

MoxoN.     Wilks  and  Moxon,  '  Pathological  Anatomy.' 
MuRCHisoN.      *  Functional  Derangement  of  the  Liver,'  2ncl 

edit. 
Neubauer  and  Vogel.    '  Urinary  Analysis '  (New  Syd.  Soc. 

Trans.). 
Newman.     Malpositions  of  the  Kidney,  '  Glasg.  Med.  Jour.' 

Aug.  1883. 
Newman.    Albuminuria,  Debate  on,  Glasgow,  'Glasg.  Med. 

Jour.'  1884. 
Oertels.     Effect  of  Exercise  on  Albuminuria,  '  Hand,  der 

Allgemeinen  Therapie,'  Ziemssen,  vol.  iv.  1884. 
Oliver.     '  Bedside  Urine  Testing,'  2nd  edit. 
Ollivier.     Saturnine  Nephritis,  '  Archives  Generales,'  ii. 

1863. 
Ord.     '  On  the  Influence  of  Colloids,  &c.'  1879. 
Parkes.     '  Composition  of  Urine  in  Health  and  Disease,' 

1860. 
Pavy.     '  Croonian  Lectures  on  Diabetes,'  1878. 
Posner.     Separation  of  Albumin,  '  Virchow,  Archiv.'  79. 
Prout.     '  Stomach  and  Kenal  Diseases,'  5th  edit. 
Eaynaud.     'De  I'Asphyxie  Locale,'  Paris,  1862. 
Eees,  Owen.     '  Calculous  Diseases,'  (Croonian  Lectures), 

1850. 
Eeynolds.     '  System  of  Medicine,'  vol.  v. 
EiEss  and   Schultzen.     Peptonuria,    '  Charite   Annalen', 

Bd.  XV.  1869. 
EiNDFLEiscH.     '  Path.  Histology,'  vol.  i.   (New  Syd.  Soc. 

Trans.). 
Egberts.     '  Urinary  and  Eenal  Diseases,'  4th  edit. 
Eobertson,  M'Gregor.    Albuminuria,  Debate  on,  Glasgow, 

'  Glasg.  Med.  Jour.'  1884. 
Eollet.    'Path,  und  Therap.  der  beweglichen  Niere,'  1866. 
Eosenstein.      Classification  of  Bright's  Disease,   '  Trans. 

Inter.  Med.  Congress,'  London,  1881. 


566  DISEASES    OF    THE    KIDNEY. 

EossENBACH.  Albuminuria, '  Zeit.  f.  klin.  Med.'  Bd.  vi.  1883. 
EuNEBEKG.      Diffusion  of  Albumin,  '  Deutsch.  Archiv  f. 

klin.  Med.'  vol.  xxiii. 
Saundby.      Histology  of  Granular  Kidney,  '  Path.    Soc. 

Trans.'  vol.  xxxi. 
Saundby.    Diabetic  Coma,  'Birmingham  Med.  Jour.'  Feb. 

1885. 
ScHUEPPEL.    Disease  of  Kidneys, '  Ziemssen's  Cyclopaedia,' 

(Eng.  Trans.),  vol.  xv. 
Seegen.     'Diabetes  Mellitus,'  2nd  edit.,  Berlin. 
Senator.      'On  Albuminuria,'   (New  Syd.   Soc.  Trans.), 

1884. 
Stewart,  Geaingek.     '  Bright's  Diseases  of  the  Kidneys,' 

2nd  edit. 
Steven,  Lindsay.      Suppurative  Nephritis,  '  Glasg.  Med. 

Jour.'  Sept.,  1884. 
Stokvis.     '  Eecherches  experimentales  sur  les  conditions 

pathogeniques  de  I'Albuminurie,'  1867. 
Tessier.     '  Du  Diabete  Phosphatique,'  Lyons,  1877. 
Thompson,  Sir  H.      '  Preventive  Treatment  of  Calculous 

Disease,'  1873. 
Trousseau.     '  Chnical  Lectures,'  (New  Syd.  Soc.  Trans.), 

vols.  ii.  and  iii. 
Tyson.    '  Guide  to  the  Practical  Examination  of  the  Urine,' 

4th  edit. 
Walter.     Diabetic  Coma,  'Archiv  f.  Exp.  Path.'  Bd.  xviii. 

Heft.  2. 
WiLKs.     Bright's  Disease,  '  Guy's  Hospital  Eeports,'  2nd 

series,  vol.  viii. 
Willis.     '  On  Urinary  Diseases,'  1837. 
Zuelzer.    '  Untersuchungen  iiber  die  Semilogie  des  Harns, " 

Berhn,  1884. 


INDEX. 


Abercrombie,  sarcomatous  growths 

of  kidney,  350 
Abnormalities    of   kidney    in    form 

and  number,  393 
Acetonsemia,    views    on,    28,     432; 

death  from,  430;    treatment  of, 

449 
Acetone,  423 
Acid  reaction  of  urine,  how  caused, 

57 
Acidity,  consequence  of,  61 ;  diurnal 

variation  of,  57 
Acquired  malposition  of  kidney,  382 
Acute  nephritis,  169 
Acute  yellow  atrophy,  urine  in,  326 
Adenoma,  853 
Afanassieu  on  hsemoglobinuria,  543, 

547 
Albumin,  test  for,  102;  clinical  es- 
timation of,   105 ;    quantitative 

determination  of,  557 
Albumins,  modified,  108 
Albuminuria,  classification  of,  158 

causes  of,  159  ;   functional,  532 

of  digestion,  535;  neurotic,  536 

physiological,  532 ;  toxic,  538 
Albuminuric  retinitis,  34 
Alkaline  urine,  62 
Alkapton,  nature  of,  and  separation, 

129 
Analysis  of  calculi,  499 
Anatomical  relations  of  kidneys,  5 
Anuria,  451 
Ammoniacal  urine,  63 
Ammonio-magnesium  phosphate,  95 
Asthma,  renal,  38 
Atkinson,   malarial    nephritis,  248, 

257 
Atrophied  granular  kidney,  208,  217. 
Aufrecht,   non-nitrogenous    diet    in 

acute  nephritis,  252 


Bacteruria,  148 

Beck,  M.,  consecutive  nephritis 
classification,  282;  causes  of, 
283;  morbid  anatomy  of,  285- 
uroemic  convulsions  in,  2S9 

Benzoic  acid  in  urine,  87 

Bile  in  urine,  tests  for,  112;  spectro- 
scopic characters  of,  69 

Bile  acids  in  jaundice,  114;  Dr. 
Oliver's  new  test  for,  488 

Bilharzia  hasmatobia,  364 

Blood,  detection  of,  in  urine,  115 

Calcareous  degeneration,  328 
Calculi,  origin  of,  460;  etiology  of, 

501;  analysis  of,  499;  treatment 

of,  509 
Calculous  degeneration  of  renal  cells, 

464 
Calculous  pyelitis,  512 
Cancer  of  the  kidney,  339 
Cantani,   dropsical   degeneration   of 

epithelium    in     diabetes,     441; 

lactic   acid,    treatment    of    dia- 


Cardio-vascular  changes,  nature  of, 
15;  in  chronic  nephritis,  224 

Casts,  characters  of,  141 

Cataract  in  diabetes,  37 

Causation  of  albuminuria,  159 

Cayley,  congenital  renal  cyst  with 
hydatids,  313 

Chateaubourg  physiological  albu- 
minuria, 106 

Cheyne,  micro-organisms,  elimina- 
tion of,  by  kidneys,  144 

Chlorides,  elimination  of,  101 ;  esti- 
mation of,  557 

Cholesterin,  146 

Chronic  tubal  nephritis,  200 


568 


DISEASES    OF    THE    KIDNEY. 


Chronic  interstitial  nephritis,  218 

Chyluria,  373;  relation  to  filarise, 
372 ;  analysis  of  fatty  matters 
in,  145 

Clark,  Sir  Andrew,  extra  renal  al- 
buminuria, 139;  discussion  on 
catheter  fever,  282,  renal  in- 
adequacy, 399,  451 

Classification  of  Bright's  disease, 
153,  158 

Clinical  examination  of  urine,  48 

Colic,  renal,  509 

Collapse,  death  from,  in  diabetes, 
430 

Colouring  matters  of  the  urine,  65 

Coma,  death  from,  in  Bright's  dis- 
ease, 23;  in  diabetes  mellitus, 
30,  430 

Congenital  renal  cysts,  312 

Congenital  malpositions  of  kidney, 
381 

Consecutive  nephritis,  282 

Constipation  as  a  symptom  of  renal 
disease ,  44 

Coupland,  on  lymphadenoma,  354 

Curgenven,  mycelium  in  urinary 
tract,  379 

Cyanotic  induration  of  kidneys,  250 

Cystic  degeneration  congenital,  312; 
after  birth,  314 

Cystic  degeneration,  primary  cystic 
formation,  314;  secondary  cys- 
tic formation,  816 

Cystin,  characters  of,  132;  calculi, 
analysis  of,  5 

Cystinuria,  487 


Davy,  rectal  lever  in  urinary  dia- 
gnosis, 319,  395 

Deposits,  of  earthy  phosphate,  93; 
ammonio-magnesium  phosphate, 
96 ;  derived  fi-om  the  urinary 
passages,  134;  separated  from 
the  urine,  150  ;  of  uric  acid  and 
urates,  84;  oxalate  of  lime,  P8  ; 
mucus,  134;  pus,  138 

Dermoid  cysts,  328 

Diabetes  insipidus,  396;  mellitus, 
4U9 

Diarrhoea,  as  a  general  symptom,  44 

Dickinson,  cold  as  a  cause  of  nephri- 
tis, 179;  nature  of  lardaceous 
deposit,  309;  nerve  us  lesions  in 
diabetes,  436 


Diet,  in  acute  nephritis,  252; 
chronic  tubal  nephritis,  262 ; 
granular  kidney,  266 ;  suppura- 
tive nephritis,  291 ;  chyluria, 
875;  hydruria,  407;  polyuria, 
409 ;  saccharine  diabetes,  441 
lithuria,  526  ;  oxaluria,  528  ; 
phosphaturia,  530;  functional 
albuminuria,  541 ;  hemoglo- 
binuria, 553 

Diffuse  inflammation  of  kidneys, 
153 

Digestion,  albuminuria  of,  535 

Doran,  Alban,  suppurative  nephri- 
tis after  operation  on  the  inter- 
nal genital  organs,  284 

Dropsy,  as  a  general  symptom,  10; 
in  acute  nephritis,  176 ;  in 
chronic  nephritis,  201 

Duke,  albuminuria  in  young  persons, 
538 

Duncan,  Matthews,  albuminuria  in 
parametritis,  181,  285,  538  ;  dia- 
betes in  pregnancy,  414 

Dupre,  potash  in  lardaceous  deposit, 
309 

Dyspepsia,  character  of,  in  granular 
kidney,  43,  226;  cause  of,  in 
chronic  nephritis,  232 


Eczema  in  diabetes,  46 

Embleton,  case  of  nephritis  treated 
with  skim  milk,  262 

Endemic  hsematuria,  364 

Enlargements  of  kidney,  distin- 
guishing points  of,  8 

Entozoa  found  in  urine,  149 

Epithelium  of  genito-urinary  tract, 
varieties  of,  135 

Etiology  of  stone,  501 

Eve,  primary  cystic  formation,  315 ; 
myo-sarcomata,  353 

Ewart,  cystic  degeneration  from  ob- 
struction, 313 

Extraneous  matters  in  urine,  149 

Extra  renal  albuminuria,  159 


Fat  in  urine,  144,  326 
Patty  degeneration,  325 
Fatty  granular  kidney,  208,  217 
Fatty  matters,  separation  of,  144 
Fagge,  Hilton,  fatty  cancer  of  kid- 
ney, 348 


INDEX. 


569 


Fayrer,  Sir  J.,  lardaceous  degenera- 
tion and  malarial  disease,  301 

Filaria  sanguinis  hominis,  370 

Finlayson,  absorption  of  albumin  by 
vesical  epithelium,  161 

Functional  albuminuria,  159 


Garrod,  lead,  a  cause  of  nephritis, 
232;  gouty  kidney,  uratic  de- 
posits in,  240 

Gee,  diminution  of  phosphates  in 
ague,  93 

Glomeruli,  changes  in,  157)  215 

Glomerulo- nephritis,  192 

Glucose,  tests  for,  in  urine,  119; 
clinical  estimation  of,  123; 
volumetric  estimation  of,  558 

Glycosuria,  409  ;  distinguished  from 
true  diabetes,  426 

Goodhart,  lardaceous  degeneration 
and  pyrexia,  303;  colloid  cancer 
of  renal  pelvis,  346 

Gouty  kidney,  230,  240;  glycosuria, 
417  ;  treatment  of,  446 

Gowers,  albuminuric  retinitis,  34 

Granular  contracted  kidney,  histo- 
logy of,  241 ;  nature  of  paren- 
chymatous degeneration,  327 

Greenfield,  histology  of  granular 
kidney,  158,  215,  241 

Gull  and  Sutton,  cardio-vascular 
changes  in  granular  kidney,  16, 
265 


H-EMATOBTA,  hilharzia,  364 

Hasmaturia  as  a  general  symptom, 
IIS;  in  acute  nephritis,  174; 
in  renal  cancer,  342 ;  endemic, 
365  ;  from  stone,  513 

Hsemoglobinuria,  542 

Haasar's  co-efficient,  52 

Hairs  from  dermoid  cysts,  character 
of,  325 

Hamilton, causation  of  albuminuria, 
161,  167;  fat  emboli  in  diabetes, 
438  ;  diminished  urinary  secre- 
tion in  acute  nephritis,  cause 
of,  452 

Harley,  J.,  on  endemic  hsematuria, 
366 

Heidenhain,  function  of  renal  epi- 
thelium, 163,  451 

Hippuric  acid,  character  of,  86 


Holmes,  pulsating  tumours  of  kid- 
ney, 342 

Hydatid  cysts,  356 

Uydro-nephrosis,  316;  fluid  of,  dis- 
tinguished from  hydatid  cyst, 
321 

Hydruria,  397 


Insipid  diabetes,  396 

Indican,  67 

Internal  organs  of  generation,  sup- 
purative nephritis  following 
operations  on,  284;  albuminuria 
in  inflammation  of,  181,  285 

Impetigo  in  diabetes,  47 

Inosite  in  urine,  126 ;  in  diabetes, 
424  _ 

Itching  in  chronic  Bright's  disease, 
24,  225 


Johnson,  G.,  cardio-vascular 
changes  in  granular  kidney,  16  ; 
milk  diet  in  nephritis,  262 

Klebs,  glomerulo  -  nephritis,  192  ; 
formation  of  cysts,  240  ;  dimin- 
ished urinary  secretion  in  acute 
nephritis,  cause  of,  452 

Kidd,  heredity  in  granular  kidney, 
229 

Kidneys,  anatomical  relation  of,  5  ; 
malpositions  of,  381;  malforma- 
tions of,  393 

Kiener  and  Kelsch,  malarial  albu- 
minaria,  248 

Klein,  glomerulo-nephritis,  194;  di- 
minished urinary  secretion  in 
acute  nephritis,  cause  of,  452 

Kreatinin,  separation  of,  89 

Kiissmaul's  coma,  28,  430 


L^VULOSE  in  urine,  128 

Lactic  acid  in  urine,  17 

Lactosuria,  128 

Lardaceous  degeneration,  300 

Large  white  kidney,  468 

Lecithin  in  urine,  144 

Lead  as  a  cause  of  nephritis,   231, 

248 
Le  Nobel,  views  on  acetonfemia,  424 
Leube,  albuminuria   after  exercise, 

166 


570 


DISEASES    OF   THE    KIDNEY. 


Leucin,  character  of,  130 
Lipsemia  in  diabetes,  438 
Lithuria,  467 

Lobulated  fatty  growths,  354 
Lymphadenoma,  354 


Mackenzie,  Stephen,  hyaline  aiid 
lardaceous  degeneration,  311 ; 
hsemato-chyluria,  371 

Mahomed,  pre-albuminuric  stage  of 
acute  nephritis,  174 

Malaria,  cause  of  albuminuria,  207, 
248 

Malarial  nephritis,  257 

Mansen  on  filaria  Bancrofti,  370 

McCarthy,  removal  of  cancerous 
kidney,  349  j  unusual  renal  cal- 
culi, 498 

Melanin,  70 

Melanotic  sarcoma,  353 

Mendelson,  renal  circulation  in  py- 
rexia, 328 

Micro-organisms  in  urine,  148;  in 
renal  tubules,  suppurative  ne- 
phritis, 287;  elimination  of,  by 
kidneys,  244 

Milk  diet,  absolute  in  chronic  ne- 
phritis, 262 

Minkowski,  oxybutyric  acid  in  dia- 
betic urine,  424 

Miscellaneous  urinary  concretions, 
498 

Modified  albumins,  108 

Molecular  coalescence,  and  the  for- 
mation of  stone,  461 

Moore,  Norman,  cancer  of  kidney 
following  calculus,  340 

Morris,  Henry,  hydro-nephrosis  re- 
marks on,  317 

Moxon,  disappearance  of  lardaceous 
deposits,  307 

Muco-pus,  characters  of,  139 

Mucus,  deposit  of,  in  urine,  134 

Mucus  corpuscles,  137 

Murchison,  lithsemia  as  a  cause  of 
nephritis,  233 

Mycelium  of  bladder  and  ureters, 
379 

Myo-sarcoma,  352 


Necrosis  of  renal  epithelium,  326 
Nephritis,  diffuse,  153;  acute  tubal, 
169  ;    glomerular,   192 ;  chronic 


tubal,  200;  chronic  interstitial, 
218  ;  etiological  varieties  of, 
242 ;  scarlet  fever,  242 ;  puer- 
peral, 245 ;  malarial,  248 ;  syphi- 
litic, 249;  gouty,  249;  saturnine, 
249;  treatment  of  acute  nephri- 
tis, 251;  malarial  nephritis,  257 ; 
chronic  tubal  nephritis,  258; 
chronic  interstitial  nephritis, 
265 

Newman,  malposition  of  kidneys, 
384 

Neurotic  albuminuria,  537 

Non-nitroffenous  diet  in  acute  ne- 
phritis, 252 


Obstruction  of  urinary  passages, 
effects  of,  282,  320,  456 

Oertels,  albuminuria  after  exercise, 
166       _ 

Oliver,  clinical  estimation  of  albu- 
min, 105;  test  for  bile  acids, 
488 ;  test  papers  for  albumin 
and  sugar,  104, 122      _ 

Ophthalmoscopic  changes  in  Bright's 
disease,  34 ;  in  diabetes,  37 

Origin  of  stone,  460 

Organic  albuminuria,  159 

Organized  deposits  from  urine,  table 
of,  151 

Osier,  adeno-sarcoma  of  kidney,  351 

Osteo  -  malacia,  hemi  -  albumose  in 
urine  of,  111 ;  deposits  of  car- 
bonate of  lime  in;  328 

Oxalate  of  lime  crystals,  88;  calcu- 
lus, 485  _ 

Oxalic  acid,  estimation  of,  89 

Oxaluria,  476 

Oxybutyric  acid  in  the  urine  of  dia- 
betes, 424 


Pain,  as   a    general    symptom,   2 ; 
cancer  of  kidney,  341;  calculus 
of  kidney,   511,  517;   neuralgic 
in    diabetes,    33;    in    granular 
kidney,  32,  424 
Pale  granular  kidney,  198,  216 
Paraglobulin,  separation  of,  106 
Parenchymatous  degeneration,  327 
Paroxysmal  hssmoglobinuria,  542 
Paul,    report   on    new   growths     of 
urinary  organs,  351 


571 


Pavy,  pathology  of  diabetes,  433 
Penicillium  glaucum,  147 
Pentastoma  denticulatum,  378 
Peptones,  tests  for,  108 
Peptonuria,  109 
Peri-nephritis,  292 
Phenylic  acid,  86 
Phosphoric  acid  in  urine,  91 
Phosphates,    alkaline,    91;    earthy, 

93  ;  ammonio-magnesium,  95 
Phosphaturia,  489 

Phosphorus,  unoxidised,  in  urine,  96 
Phosphorus  poisoninar,  urine  in,  163, 

326 
Phthisis,  relation  of,  to  diabetes,  41 
Physiological  albuminuria,  532 
Pigment,  particles  in  urine,  137 
Pollard,  cancer  of  kidney  following 

on  calculus,  340 
Polyuria,  396 

Posner,  place  of  separation  of  albu- 
min in  kidney,  164 
Primary  cystic  formation,  314 
Pro -peptone  (hemi-oJbumose) ,  111 
Prostatic  calculi,  497 
Psoriasis  in  diabetes,  46 
Ptomaines,  in  ursemic  poisoning,  26 
Pulmonary    complications  in  renal 

diseases,  40 
Pulmonary  oedema  in  nephritis,  177 
Pus,  deposit  of,  in  urine,  138 
Pus  corpuscles,  detection  of,  138 
Pysemic  abcesses  of  kidney,  273 
Pyelitis    and    pyo-nephrosis,     2/5  ; 
pyelo -nephrosis,  282 


Raee  renal  parasites,  378 

Raynaud's  disease,  546 

Reaction  of  urine,  56 

Rectum,  examination  by,  for  dia- 
gnosis of  renal  tumours,  319 

Rectal  lever  for  compression  of  ure- 
ters, 319,  395 

Red  granular  kidney,  199,  240 

Rees,  Owen,  views  regarding  am- 
moniacal  urine,  64;  on  formation 
of  stone,  463 

Renal  abnormalities  in  form  and 
number,  393  ;  asthma,  38,  226  ; 
circulation  in  fever,  328 ;  epithe- 
lium, characters  of,  135 ;  inade- 
quacy, 451;  colic  treatment  of, 
517 


Retention  of  urine,  455 
Respiratory    system,  derangementa 

of,  38 
Robertson,  M'Gregor,  action  of  atro- 

pine  on  renal  cells,  161 
Rosenstein,  unity  of  Bright's  disease, 

156 


Sansom,  case  of  peptonuria,  110 

Sarcinse  in  urine,  147 

Saundby,  cardio-vascular  changes  in 
granular  kidney,  18  ;  unity  of 
Bright's  disease,  156;  diabetic 
coma,  431 

Saturnine  nephritis,  231,  249 

Sarcoma  of  kidney,  350 

Secondary  cystic  formation,  316 

Scrofulous  kidney,  331 

Smith,  Pye,  iodine  reaction  on  larda- 
cein,  310;  cystic  formation,  317 

Smith,  W.,  cause  of  deposition  of 
calcium  phosphate,  94 

Solid  matters  of  the  urine,  50 

Southey,  albuminous  urine,  effect  of 
cutaneous  lesions,  181 

Specific  gravity  of  urine,  51 

Spectroscopic  examination  of  icteric 
urine,  69 ;  of  urinary  pigments, 
65  ;  of  blood  in  urine,  69 

Spermatozoa  in  urine,  148 

Steven,  Lindsay,  suppurative  ne- 
phritis, classification  of,  272  ; 
pyeemic  abscesses  of  kidney, 
273  ;  pyelo-nephrosis,  infective 
material  disseminated  by  lym- 
phatics, 284;  micro-organisms 
in  tubules,  287 

Stewart,  Grainger,  classification  of 
nephritis,  155 ;  pigmentation  of 
skin  in  lardaceous  degeneration, 
46 

Strongylus  gigas,  378 

Sugar  (See  Glucose),  119 

Sulphates,  elimination  of,  99 

Sulphur  unoxidized  in  urine,  99 

Suppression  of  urine,  451 

Suppurative  inflammation  of  the 
kidney,  272 

Surgical  kidney,  232 

Syphilis;  a  cause  of  lardaceous  do- 
generation,  300,  329 

Syphilitic  infiltration,  329;  nephri- 
tis, 249;  disease  of  renal  arteries, 
330 


572 


DISEASES    OF    THE    KLDNEY. 


Tayloe,  p.,  deaths  from  diabetic 
coma,  431 ;  treatment  of  diabe- 
tic coma,  449 

Teasier,  on  phospbatic  diabetes,  397 

Torula  cerevisise,  126,  147 

Toxic  albuminuria,  538 

Trapp's  co-efficient,  51 

Turner,  Cbarlwood,  lardaceous  de- 
generation, etiology  of,  300 

Tyrosin,  characters  of,  130 

Tyson,  pus  and  mucus  corpuscles, 
137;  casts  in  non-albuminous 
urines,  143 

Tubercular  infiltration,  337 


Urine,  systematic  examination  of,  48 ; 

suppression   of,  451  j    retention 

of,  455 
Uro-bilin,  65 
Uro-stealith,  145 


Yapour  batbs,  in  acute  nephritis, 

254  ;  in  chronic  tubal  nephritis, 

259 ,  in  diabetes,  446 
Venesection,  in  poerperal  nephritis, 

247  ;  in  diabetic  coma,  449 
Virchow,     gouty     nephritis,     230; 

glioma  of  kidney,  351 
Vomiting,  ursemic  and  reflex,  43 


ATES,  varieties  of,  81 ;  in  calculi, 
476 ;  causes  of  deposition,  471 
rea,  separation  of,  72;  clinical  es- 
timation of,  73;  variation  of,  in 
disease,  78;  quantitative  esti- 
mation of,  554 ;  in  acute  nephri- 
tis, 173 ;  chronic  tubal  nephritis, 
203 ;  chronic  interstitial  nephri- 
tis, 221 ;  suppurative  nephritis, 
289;  polyuria,  400;  diabetes 
melUtus,  420;  functional  albu- 
minuria, 538;  hsemoglobinuria, 
544 

Ursemia,  character  of  attacks,  23; 
theory  of,  25;  in  acute  nephritis, 
177;  in  granular  kidney,  224; 
in  suppurative  nephritis,  289 

Uric  acid,  separation  of,  83;  tests 
for,  80 ;  deposits  of,  84 ;  clinical 
significance  of,  471;  calculus, 
varieties  of,  473 ;  calculus  analy- 
sis, 498 

Urinary  secretion  diminished  in 
acute  nephritis,  cause  of,  450 ; 
variations  of,  50 


White,  Hales,  glycosuria  in  insan- 
ity, 413  ;  lesions  of  sympathetic 
in  diabetes,  437 

Wilks,  copaiba  in  chronic  renal 
dropsy,  260;  mineral  acids  in 
diabetes,  447 

Williams,  Dawson,  myo-sarcoma  of 
kidney,  352;  tables  of  mortality 
from  diabetes,  415 

WiUiams,  John,  puerperal  nephritis, 
venesection  in,  247 

Windle,  lung  affections  in  diabetes; 
epithelioma  of  renal  pelvis,  346 


Xanthin,  characters  of,  132;    cal- 
cuU,  486 


ZiNCAKOL  onhsematobia,  365 
Zuelzer,  glycerin-phosphoric  acid  m 
urine,    144 ;    decrease  of  phos- 
phoric acid  in  nephritis,  221 


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Nos.  2  and  3.     PRACTICE. 

A  Compend  of   the   Practice  of    Medicine,   especially 
adapted  to  the  use  of  Students.  By  Dan'l  E.  Hughes, 
M.D.,  Demonstrator  of  Clinical  Medicine  in  Jefferson 
Medical  College,  Philadelphia.     In  two  parts. 
Part  I. — Continued,  Eruptive,  and  Periodical  Fevers, 
Diseases  of  the  Stomach,  Intestines,  Peritoneum,  Biliary 
Passages,  Liver,  Kidneys,  etc.,  and  General  Diseases,  etc. 
Part  II. — Diseases  of  the  Respiratory  System,  Circu- 
latory System,  and  Nervous  System ;    Diseases   of  the 
Blood,  etc. 

***  These  little  books  can  be  regarded  as  a  full  set  of 
notes  upon  the  Practice  of  Medicine,  containing  the 
Price  of  each  Book,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


THE  ?  QUIZ-COMPENDS  ?. 


Synonyms,  Definitions,  Causes,  Symptoms,  Prognosis, 
Diagnosis,  Treatment,  etc.,  of  each  disease,  and  includ- 
ing a  number  of  new  prescriptions.  They  have  been 
compiled  from  the  lectures  of  prominent  Professors,  and 
reference  has  been  made  to  the  latest  writings  of  Pro- 
fessors Flint,  Da  Costa,  Reynolds,  Bartholow, 
Roberts  and  others. 

"  It  is  brief  and  concise,  and  at  the  same  time  possesses  an  accu- 
racy not  generally  found  in  compends." — jfas.  M.  French,  M.D., 
Ass't  to  the  Pro/,  of  Practice ,  Medical  College  of  Ohio,  Cincinnati. 

"  The  boolc  seems  very  concise,  yet  very  comprehensive.  .  .  . 
An  unusually  superior  book." — Dr.  E.  T.  Bruen,  De7nonstrator 
of  Clinical  Medicine ,  University  of  Pennsylvania. 

"  I  have  used  it  considerably  in  connection  v/ith  my  branches  in 
the  Quiz-class  of  the  University  of  La." — y.  H.  Betniss,  Neiu 
Orleans. 

"  Dr.  Hughes  has  prepared  a  very  useful  little  book,  and  I  shall 
take  pleasure  in  advising  my  class  to  use  it." — Dr.  George  IV. 
Hall,  Pr  of essoi'of  Practice,  St.  Louis  College  of  Physicians  and 
Surgeons. 

No.  4.    PHYSIOLOGY.     Second  Ed. 
A  Compend  of  Human  Physiology,  adapted  to  the  use 
of  Students.     By  Albert    P.  Brubaker,   m.d.,  De- 
monstrator of  Physiology  in  Jefferson  Medical  College, 
Philadelphia.     Second  Ed.     Enlarged  and  Revised. 
"  Dr.  Brubaker  deserves  the  hearty  thanks  of  medical  students 
for  his  Co>npend  of  Physiology.    He  lias  arranged  the  fundamental 
and  practical  principles  of  the  science  in  a  peculiarly  inviting  and 
accessible  manner.     I  have  already   introduced   the   work   to  my 
class." — Maurice  N.  Miller,  M.D.,  Instructor  in  Practical  His- 
tology,  formerly  Demonstrator  of  Physiology ,  University  City  of 
New  York. 

"  '  Quiz-Compend'  No.  4  is  fully  up  to  the  high  standard  estab-  , 
lished  by  its  predecessors  of  the  same  series." — Medical  Bulletin, 
Philadelphia. 

"  I  can  recommend  it  as  a  valuable  aid  to  the  student." — C.  JV, 
Ellintvood,  M.D.,  Professor  of  Physiology,  Cooper  Medical  Col- 
lege, San  Francisco. 

"  This  is  a  well  written  little  book." — London  Lancet. 

No.  5.     OBSTETRICS.    Second  Ed. 

A  Compend  of  Obstetrics.  For  Physicians  and  Students. 
By  Henry  G.  Landis,  m.d.,  Professor  of  Obstetrics 
and  Diseases  of  Women,  in  Starling  Medical  College, 
Columbus.  New  Revised  Ed.  New  Illustrations. 
"We  have  no  doubt  that  many  students  will  find  in  it  a  most 
valuable  aid  in  preparing  for  examination." — The  American  Jour- 
nal of  Obstetrics. 

"  It  is  complete,  accurate  and  scientific.  The  very  best  book  of 
its  kind  I  have  seen." — jf.  S.  Knox,  M.D.,  Lecturer  on  Obstetrics, 
Rush  Medical  College,  Chicago. 

Price  of  each  Book,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


THE  f  QUIZ-COMPENDS  ?. 


"  I  have  been  teaching  in  this  department  for  many  years,  and  am 
free  to  say  that  this  will  be  the  best  assistant  I  ever  had.  It  is  ac- 
curate and  comprehensive,  but  brief  and  pointed." — Prof.  P.  D, 
Yost,  St.  Louis. 

No.  6.    MATERIA  MEDIOA.    Revised  Ed. 

A  Compend  on  Materia  Medica  and  Therapeutics,  with 
especial  reference  to  the  Physiological  Actions  of 
Drugs.  For  the  use  of  Medical,  Dental,  and  Pharma- 
ceutical Students  and  Practitioners.  Based  on  the  New 
Revision  (Sixth)  of  the  U.  S.  Pharmacopoeia,  and  in- 
cluding many  unofficinal  remedies.  By  Samuel  O. 
L.  Potter,  M.A.,M.D.,  U.  S.  Army. 

"  I  have  examined  the  little  volume  carefully,  and  find  it  just 
such  a  book  as  I  require  in  my  private  Quiz,  and  shall  certainly  re- 
commend it  to  my  classes.  Your  Compends  are  all  popular  here  in 
Washington." — jfohn  E.  Brackett,  M.D.,  Professor  of  Materia 
]\Iedica  and  Therapeutics ,  Howard  Medical  College,  Washington. 

"  Part  of  a  series  of  small  but  valuable  text-boolcs.  .  .  .  While 
the  work  is,  owing  to  its  therapeutic  contents,  more  useful  to  the 
medical  student,  the  pharmaceutical  student  may  derive  much  use- 
ful information  from  it." — N.  Y.  Pharmaceutical  Record. 

No.  7.     CHEMISTRY.    Revised  Ed. 

A  Compend  of  Chemistry.     By  G.  Mason  Ward,  m.d., 
Demonstrator  of  Chemistry  in  Jefferson  Medical  Col- 
lege, Philadelphia.    Including  Table  of  Elements  and 
various  Analytical  Tables. 
"  Brief,  but  excellent.   ...  It  will  doubtless  prove  an  admirable 

aid  to  the  student,  by  fixing  these  facts  in  his  memory.     It  is  worthy 

the  study  of  both  medical  and  pharmaceutical   students   in   this 

branch." — Pharinaceutical  Record,  Nezu  York. 

No.  8.    VISCERAL  ANATOMY. 

A  Compend  of  Visceral  Anatomy.  By  Samuel  O.  L. 
Potter,  m.a.,  m.d.,  U.  S.  Army.    With  40  Illustrations. 

*i^  This  is  the  only  Compend  that  contains  full  descriptions  of  the 
viscera,  and  will,  together  with  No.  i  of  this  series,  form  the  only 
complete  Compend  of  Anatomy  published. 

No.  9.     SURGERY.     Second  Edition. 

A  Compend  of  Surgery;  including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations  and  other  opera- 
tions, Inflammation,  Suppuration,  Ulcers,  Syphilis, 
Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear,  Eye, 
Bladder,  Testicles,  Anus,  and  other  Surgical  Diseases. 
By  Orvtlle  Horwitz,  a.m..  m.d.,  with  62  Illustra- 
tions.    Second  Edition.     Enlarged  and  Revised. 

Price  of  Each  Book,  Cloth,  $1.00.    Interleaved  for  Notes,  $1.25. 


THE  ?QUIZ-COMPENDS?. 


No.  10.     ORGANIC  CHEMISTRY. 

JUST  PUBLISHED. 

A  Compend  of  Organic  Chemistry,  including  Medical 
Chemistry,  Urine  Analysis,  and  the  Analysis  of  Water 
and  Food,  etc.  By  Henry  Leffmann,  m.d.,  Pro- 
fessor of  Clinical  Chemistry  and  Hygiene  in  the  Phila- 
delphia Polyclinic ;  Professor  of.  Chemistry,  Penn- 
sylvania College  of  Dental  Surgery ;  Member  of  the 
N.  Y.  Medico-Legal  Society.  Cloth,     ^i.oo. 

Interleaved,  for  the  addition  of  Notes,  ^1.25. 

No.  11.     PHARMACY. 

A  Compend  of  Pharmacy.  By  Louis  Genots,  Ph.  G., 
Member  of  the  American  Pharmaceutical  Association. 

Cloth.     $1.00. 
Interleaved,  for  the  addition  of  Notes,  $1.25. 

The  Essentials  of  Pathology. 

BY  D.  TOD  GILLIAM,  M.D., 

Professor  of  Physiology  in  Starling  Medical  College,  Columbus ,  O. 

With  47  Illustrations.    12mo.    Cloth.    Price  $2.00. 

*#*  The  object  of  this  book  is  to  unfold  to  the  beginner  the  funda- 
mentals of  pathology  in  a  plain,  practical  way,  and  by  bringing  them 
within  easy  comprehension  to  increase  his  interest  in  the  study  of 
the  subject.  Though  it  will  not  altogether  supplant  larger  works, 
it  will  be  found  to  impart  clear-cut  conceptions  of  the  generally 
accepted  doctrines  of  the  day,  and  to  prevent  confusion  in  the  mind 
of  the  student. 


A  POCKET-BOOK  OF 

PHYSICAL    DIAGNOSIS 

OF  THE 

Diseases  ofihe  Heart  and  Lungs. 

A  MANUAL  FOR   STUDENTS   AND   PHYSICIANS. 
BY  DR.  EDWARD  T.  BRUEN, 

Demonstrator  of  Clinical  Medicine  in  the  University  of  Pennsyl- 
vania, Assistant  Physician  to  the  University  Hospital,  etc. 

Second  Edition,  Revised.    With  new  Illustrations.    12mo.    $1.50 

***The  subject  is  treated  in  a  plain,  practical  manner,  avoiding 
questions  of  historical  or  theoretical  interest,  and  without  laying 
special  claim  to  originality  of  matter,  the  author  has  made  a  book 
that  presents  the  somewhat  difficult  points  of  Physical  Diagnosis 
clearly  and  distinctly. 


STUDENTS'  MANUALS. 


GOODHART  AND  STARR  ON  DISEASES 
OF  CHILDREN.  A  Practical  Guide  for  Students. 
Demi-Octavo.  Cloth,  $3.00;  Leather,  34.00. 

LANDOIS'      MANUAL     OF     PHYSIOLOGY. 

With  Special  Refei-ence  to  Practical  ]\Iedicine.     Vol. 
I,  with  176  Illustrations.     8vo.  Cloth,  34-50. 

Vol.  II.  Nearly  Ready. 

TYSON,  ON  THE  URINE.  A  Practical  Guide  to 
the  Examination  of  Unne.  For  Physicians  and  Stu- 
dents. By  James  Tyson,  m.d.,  Professor  of  Path- 
ology and  Morbid  Anatomy,  University  of  Pennsylva- 
nia. With  Colored  Plates  and  Wood  Engravings. 
Fourth  Edition.  i2mo,  cloth,  $1.50 

HEATH'S  MINOR  SURGERY.  A  Manual  of 
Minor  Surgery  and  Bandaging.  By  CHRISTOPHER 
Heath,  m.d..  Surgeon  to  University  College  Hospital, 
London.     6th  Edition.     115  111.     1 2mo,  cloth,  ^2.00 

MACNAMARA,  ON  THE  EYE.  A  Manual  for 
Students  and  Physicians.  4  Colored  Plates  and  65 
Wood  Engravings.     Demi  8vo.  Cloth,  ^4.00. 

DULLES'  ACCIDENTS  AND  EMERGEN- 
CIES. What  To  Do  First  in  Accidents  and  Emer- 
gencies. A  Manual  Explaining  the  Treatment  of 
Surgical  and  other  Accidents,  Poisoning,  etc.  By 
Charles  W.  Dulles,  m.d.,  Surgeon  Out-door  De- 
partment, Presbyterian  Hospital,  Philadelphia.  Col- 
ored Plate  and  other  Illustrations.        32mo,  cloth,  .75 

BEALE,  ON  SLIGHT  AILMENTS.  Their  Na- 
ture and  Treatment.  By  Lionel  S.  Beale,  m.d., 
F.R.s.  Second  Edition.  Revised,  Enlarged  and  Illus- 
trated.    283  pages.     8vo. 

Paper  covers,  75  cents;  cloth,  $\.2.^ 

ALLINGHAM,  ON  THE  RECTUM.  Fistulse, 
Hemorrhoids,  Painful  Ulcer,  Stricture,  Prolapsus,  and 
other  Diseases  of  the  Rectum ;  Their  Diagnosis  and 
Treatment.  By  Wm.  Allingham,  m  d.  Fourth  Re- 
vised and  Enlarged  Edition.     Illustrated.     8vo. 

Paper  covers,  75  cents;  cloth,  ^1.25 


STUDENTS'  MANUALS  AND  LEXICONS. 

MARSHALL  AND  SMITH,  ON  THE  URINE. 

The  Chemical  Analysis  of  the  Urine.  By  John  Mar- 
shall, M.D.,  Chemical  Laboratory,  University  of  Penn- 
sylvania, and  Prof.  E.  F.  Smith.  Illus.  Cloth,  ^i.oo 

MEARS'  PRACTICAL  SURGERY.  Surgical 
Dressings,  Bandaging,  Ligation,  Amputation,  etc.  By 
J.  EwiNG  Mears,  M.D.,  Demonstrator  of  Surgery  in 
Jefferson  Med.  College.  227  Illus.    2d  Ed.     In  Press. 

KIRKE'S  PHYSIOLOGY.  A  Handbook  for  Stu- 
dents. Eleventh  Edition,  1884.  466  Illustrations. 
Demi  8vo.  Cloth,  ^5.00 

TYSON,  ON  THE  CELL  DOCTRINE;  its  His- 
tory and  Present  State.  By  Prof.  James  Tyson,  m.d. 
Second  Edition.     Illustrated.  i2mo,  cloth,  ^2.00 

MEADOWS'  MIDWIFERY.  A  Manual  for  Stu- 
dents.  By  Alfred  Meadows,  m.d.  From  Fourth 
London  Edition.     145  Illustrations.    8vo,  cloth,  ^2.00 

WYTHE'S  DOSE  AND  SYMPTOM  BOOK. 
Containing  the  Doses  and  Uses  of  all  the  principal 
Articles  of  the  Materia  Medica,  etc.  Eleventh  Edi- 
tion.        32mo,  cloth,  ^i.oo;  pocket-book  style,  $1.25 

PHYSICIAN'S  PRESCRIPTION  BOOK.  Con- 
taining Lists  of  Terms,  Phrases,  Contractions  and 
Abbreviations  used  in  Prescriptions,  Explanatory  Notes, 
Grammatical  Construction  of  Prescriptions,  etc.,  etc. 
By  Prof.  Jonathan  Pereira,  m.d.  Sixteenth  Edi- 
tion.        32mo,  cloth,  ^i.oo;  pocket-book  style,  $1.25 

POCKET  LEXICONS. 

CLEAVELAND'S  POCKET  MEDICAL  LEXI- 
CON. A  Medical  Lexicon,  containing  correct  Pro- 
nunciation and  Definition  of  Terms  used  in  Medi- 
cine and  the  Collateral  Sciences.  Thirtieth  Edition. 
Very  small  pocket  size.     Red  Edges. 

Cloth,  75  cents;  pocket-book  style,  ^i.oo 

LONGLEY'S    POCKET    DICTIONARY.      The 

Student's  Medical  Lexicon,  giving  Definition  and  Pro- 
nunciation of  all  Terms  used  in  Medicine,  with  an 
Appendix  giving  Poisons  and  Their  Antidotes,  Abbre- 
viations used  in  Prescriptions,  Metric  Scale  of  Doses, 
etc.  24mo,  cloth,  ^i.oo;  pocket-book  style,  J5S1.25 


REESE'S 
MEDICAL   JURISPRUDENCE 

AND  TOXICOLOGY. 

A  Text-book  of  Medical  Jurisprudence  and  Toxicology.  By 
John  J.  Reese,  m.  d.,  Professor  of  Medical  Jurisprudence  and 
Toxicology  in  the  Medical  and  Law  Departments  of  the  University 
of  Pennsylvania;  Vice-President  of  the  Medical  Jurisprudence  So- 
ciety of  Philadelphia;  Physician  to  St.  Joseph's  Hospital;  Corres- 
ponding Member  of  the  New  York  Medico-legal  Society.  One 
Volume.    Demi  Octavo.    606  pages.    Cloth,  $4.00  ;  Leather,  ^5.00. 

"  Professor  Reese  is  so  well  known  as  a  skilled  medical  jurist 
that  his  authorship  of  any  work  virtually  guarantees  the  thorough- 
ness and  practical  character  of  the  latter.  And  such  is  the  case  in 
the  book  before  us.  *  *  *  *  We  might  call  these  the 
essentials  for  the  study  of  medical  jurisprudence.  The  subject 
is  skeletonized,  condensed,  and  made  thoroughly  up  to  the  wants  of 
the  general  medical  practitioner,  and  the  requirements  of  prose- 
cuting and  defending  attorneys.  If  any  section  deserves  more  dis- 
tinction than  any  other,  as  to  intrinsic  excellence,  it  is  that  on  toxi- 
cology. This  part  of  the  book  comprises  the  best  outline  of  the 
subject  in  a  given  space  that  can  be  found  anywhere.  As  a  whole, 
the  work  is  everything  it  promises  and  more,  and  considering  its 
size,  condensation,  and  practical  character,  it  is  by  far  the  most 
useful  one  for  ready  reference  that  we  have  met  with.  It  is  well 
printed  and  neatly  bound. — iV.  V.  Medical  Record,  Sept.  13th,  1884. 


RICHTER'S  CHEMISTRY, 

A  TEXT-BOOK  of  INORGANIC  CHEMISTRY  for  STUDENTS. 

By  PROF.  VICTOR  .von  RICHTER, 

University  of  Breslau, 

Authorized  Translation  from  the  Third  German  Edition, 

By  EDGAR  F.  SMITH,  M.A.,  Ph.D., 

Professor  of  Chemistry  in  Wittenberg  College,  Springfield,  Ohio  ; 
forjnerly  in  the  Laboratories  of  the  University  of  Pennsyl- 
vania; Member  of  the  Chetnical  Society  of  Berlin. 

12tno.  89  Wood-cuts  and  CoL  Lithographic  Plate  of  Spectra.  $2.00 

In  the  chemical  text-books  of  the  present  day,  one  of  the  striking 
features  and  difficulties  we  have  to  contend  with  is  the  separate 
presentation  of  the  theories  and  facts  of  the  science.  These  are 
usually  taught  apart,  as  if  entirely  independent  of  each  other,  and 
those  experienced  in  teaching  the  subject  know  only  too  well  the 
trouble  encountered  in  attempting  to  get  the  student  properly  in- 
terested in  the  science  and  in  bringing  him  to  a  clear  comprehension 
of  the  same.  In  this  work  of  Prop,  von  Richter,  which  has  been 
received  abroad  with  siich  hearty  welcome,  two  editions  having 
been  rapidly  disposed  of,  theory  and  fact  are  brought  close  together, 
and  their  intimate  relation  clearly  shown.  From  careful  observa- 
tion of  experiments  and  their  results,  the  student  is  led  to  a  correct 
understanding  of  the  interesting  principles  of  chemistry. 

In  preparation,  "ORGANIC  CHEMISTRY,"  By  the  same 
author  and  translator. 


YEO'S   PHYSIOLOGY. 

A  MANUAL  FOR  STUDENTS.     JUST  READY. 
300     CAREFULLY    PRINTED    ILLUSTRATIONS. 

FULL  GLOSSARY  AND  INDEX. 
By  Gerald  F.  Yeo,  m.d.,  f.r.c.s.,  Professor  of  Physi- 
ology in  King's  College,  London.    Small  Octavo.    750 
pages.     Over  300  carefully  printed  Illustrations. 

PRICE,  CL«TH,  $4.00;  LEATHER,  $5.00. 

"  By  his  excellent  manual,  Prof.  Yeo  has  .supplied  a  want  which 
must  have  been  felt  by  every  teacher  of  physiology.  *  *  *  * 
In  conclusion,  we  heartily  congratulate  Prof.  Yeo  on  his  work, 
which  we  can  recommend  to  all  those  who  wish  to  find  within  a 
moderate  compass  a  reliable  and  pleasantly  written  exposition  of 
all  the  essential  facts  of  physiology  as  the  science  now  stands." — 
The  Dublin  Journal  of  Med.  Science. 

"The  work  will  take  a  high  rank  among  the  smaller  text-books 
of  Physiology." — Prof.  H.  P.  Bowditch,  Harvard  Med.  School, 
Boston. 

"  The  brief  examination  I  have  given  it  was  so  favorable  that  I 
placed  it  in  the  list  of  text-books  recommended  in  the  circular  of 
the  University  Medical  College." — Prof.  Lewis  A.  Stinipson, 
M.  D  ,  s^  East  33d  Street,  New  York. 

"  For  students'  use  it  is  one  of  the  very  best  text-books  in  Physi- 
ology."—  Prof.  L.  B.  How,  Dartmouth  Med.  College,  Hanover, 
N.H. 

RINDFLEISCH. 

THE  ELEMENTS  OF  PATHOLOGY. 

TRANSLATED  BY  WM.  H.  MERCUR,  M.D. 
REVISED   AND   EDITED   BY  PROF.  JAS.  TYSON, 

Of  the  University  of  Pennsylvania. 
263  PAGES.  CLOTH.  PRICE  §2.00. 
*.j(.*It  is  the  object  of  Prof.  Rindfleisch  to  present  in 
this  volume  of  moderate  size  the  fundamental  principles 
of  Pathology  A  large  number  of  the  general  processes 
which  underlie  disease,  a  knowledge  of  which  is  essen- 
tial to  the  practical  physician,  are  plainly  presented. 
They  include,  among  others,  inflammation,  tumor  forma- 
tion, fever,  derangements  of  nutrition,  including  atrophy, 
derangements  of  the  movement  of  the  blood,  of  blood 
formation  and  blood  purification,  hypersesthesia,an£esthe- 
sia,  convulsions,  paralysis,  etc.  The  well-known  reputa- 
tion of  the  author,  his  thorough  familiarity  with  and  his 
method  of  treating  the  subject,  make  this  most  recent  work 
peculiarly  useful  to  the  student,  as  well  as  to  the  prac- 
ticing physician  who  wishes  to  brush  up  his  pathology. 


Jiist  Published. 

VAN  HARLINGEN  ON  SKIN  DISEASES. 

A  Handbook  of  the  Diseases  of  the  Skin,  their  Di- 
agnosis and  Treatment.  By  Arthur  Van  Harlingen,  M.D., 
Professor  of  Diseases  of  the  Skin  in  the  Philadelphia 
Polyclinic,  Consulting  Physician  to  the  Dispensary  for 
Skin  Diseases,  etc.  Illustrated  by  two  colored  litho- 
graphic plates. 

12mo.  284  PAGES.  CLOTH.  gRICE  $1.75. 
***This  is  a  complete  epitome  of  skin  diseases,  arranged  in  al- 
phabetical order,  giving  the  diagnosis  and  treatment  in  a  concise, 
practical  way.  Many  prescriptions  are  given  that  have  never  been 
published  in  any  text-book,  and  an  article  incorporated  on  Diet. 
The  plates  do  not  represent  one  or  two  cases,  but  are  composed  of  a 
number  of  figures,  accurately  colored,  showing  the  appearance  of 
various  lesions,  and  will  be  found  to  give  great  aid  in  diagnosing. 

BYFORD,  DISEASES  OF  WOMEN. 

NEW  REVISED  EDITION. 
The  Practice  of  Medicine  and  Surgery,  as  applied  to  the 
Diseases  of  Women.  By  W.  H.  Byford,  a.m.,  m.d., 
Professor  of  Gynaecology  in  Rush  Medical  College; 
of  Obstetrics  in  the  Woman's  Medical  College ;  Sur- 
geon to  the  Woman's  Hospital;  President  of  the 
American  Gynsecological  Society,  etc.  Third  Edilion. 
Revised  and  Enlarged;  much  of  it  Rewritten;  with 
over  1 60  Illustrations.     Octavo. 

PRICE,  CLOTH,  $5.00;  LEATHER,  $6.00. 
"  The  treatise  is  as  complete  a  one  as  the  present  state  of  our 
science  will  admit  of  being  written.  We  commend  it  to  the  diligent 
study  of  everj'  practitioner  and  student,  as  a  work  calculated  to  in- 
culcate sound  principles  and  lead  to  enlightened  practice  " — New 
York  Medical  Record. 

"  The  author  is  an  experienced  writer,  an  able  teacher  in  his  de- 
partment, and  has  embodied  in  the  present  work  the  results  of  a 
wide  field  of  practical  observation.  We  have  not  had  time  to  read 
its  pages  critically,  but  freely  commend  it  to  all  our  readers,  as  one 
of  the  most  valuable  practical  works  issued  from  the  American 
press." — Chicago  Medical  Exatniner. 

MACKENZIE,  THE  THROAT  AND  NOSE. 

By  MoRELL  Mackenzie,  m.d..  Senior  Physician  to  the 

Hospital  for  Diseases  of  the  Chest  and  Throat;  Lecturer 

on  Diseases  of  the  Throat  at  the  London  Hospital,  etc. 

Vol.  I.   Including  the  Pharynx,  Larynx,  Trachea, 

etc.     1 1 2  Illustrations.    Cloth,  ^4.00;  Leather,  $5.00 

Vol.  II.    Diseases  of  the  CEsophagus,  Nose  and 

Naso-pharynx,  with  Formula  and  93  Illustrations. 

Cloth,  $3.00;  Leather,  ;?4.oo 

The  two  volumes  at  one  time.    Cloth,  $6.00  ;  Leather,  $7.50. 


T^C3o^ 


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